Hepatitis C Medications

Prior Authorization is required for hepatitis C treatment. Prior Authorization Submission Requirements are below

The following MUST be submitted to MFC-DC for a request for hepatitis C treatment to be processed:

  1. A completed Hepatitis C Prior Authorization Form.  
  2. Medical records including:
    1. Most recent office visit note(s) which includes:
      1. Detail on all previous hepatitis C treatments; if none, the note must say “treatment naïve.”
      2. Child-Pugh score (if cirrhotic).
      3. Social history with detail provided on use of ETOH and/or illicit substances.
  1. Laboratory studies including:
    1. a recent (less than 6 months old) baseline viral load.
    2. genotype.
    3. fibrosis scoring (FibroSure, FibroTest, FibroScan, liver biopsy).
    4. (If applicable) HIV viral load and/or hepatitis B viral load.

Submit the completed form and required documentation via fax to 202-243-6258.

For questions or concerns, please contact Dr. Danielle Gerry at 410-933-2295.

Information current as of: 10/20/20