Billing hepatitis C medications for Apple Health clients
All hepatitis C (HCV) medications are paid for by the Apple Health (Medicaid) fee-for-service (FFS) program. Mavyret does not require prior authorization (PA). All other HCV medications require PA. For coverage criteria please see the Antivirals - Hepatitis C Treatment policy.
To bill FFS for an HCV medication prescribed to a client enrolled in an Apple Health Managed Care Plan, include a “2” in the Claim Segment, Prior Authorization Type Code (461-EU) field. All FFS rules apply, including authorization requirements.
If a pharmacy claim for an HCV medication is billed to an Apple Health Managed Care Plan, you will receive the following rejection message:
| Apple Health Managed Care Plan |
Message Line 1 |
Message Line 2 |
| Amerigroup |
Product Service ID Carve-Out Bill Medicaid Fee for Service. |
Excluded NDC, Bill WA FFS BIN 610706 Plan Exclusion |
| Community Health Plan |
Product/services not covered |
Bill HCA FFS- Call 800-562-3022
|
| Coordinated Care |
Bill to Health Care Authority |
Contact HCA at 800-562-3022. Plan Exclusion. |
| Molina |
831 Bill Medicaid FFS |
Plan Exclusion bill to Provider One |
| United Health |
Bill Fee For Service |
|
For questions, please email us at AppleHealthPharmacyPolicy@hca.wa.gov
|
