MedicaidPrior AuthMedium impact
Newsletter Vol. 34, No.10
New Jersey Medicaid·NJ · Family Medicine, Internal Medicine, Infectious Disease +1 more·Medical Policy
Effective date
Sep 1, 2024
We identified it
Jun 20, 2026
Summary
New Jersey expanded coverage for Hepatitis C Direct Acting Antivirals (DAAs) with simplified prior authorization. Treatment-naïve members no longer need prior auth if proper diagnosis codes are documented, while treatment-experienced members still require prior authorization with detectable virus levels within 90 days.
Action Required
Immediately: Billing team must ensure pharmacies verify hepatitis C diagnosis with prescribers for treatment-naïve members using ICD-10 codes B1710, B1711, B182, B1920, or B1921 in Field 424-DO with Diagnosis Code Qualifier '02' in field 492-WE on pharmacy claims. Providers should document associated diagnosis codes on DAA prescriptions. Treatment-experienced members still require prior authorization with detectable hepatitis C virus level within past 90 days.