MedicaidPrior AuthMedium impact
Prior Authorization of Sovaldi and Other Medications for the Treatment of Chronic Hepatitis C
Illinois Medicaid - HFS·IL · Gastroenterology, Infectious Disease, Internal Medicine +1 more·Provider Notice
Effective date
Aug 8, 2014
We identified it
Jun 20, 2026
Summary
Illinois Medicaid now requires prior authorization for Sovaldi and other Hepatitis C medications with strict eligibility criteria including substance abuse screening, pregnancy testing, and specialist consultation requirements. The policy establishes a 'once in a lifetime' treatment limit with 2-week dispensing intervals and mandatory progress reporting.
Action Required
Immediately: Update prior authorization procedures for Hepatitis C medications (Sovaldi) for Illinois Medicaid patients. Billing team must verify all 18 eligibility criteria are met before treatment including: substance abuse screening within 12 months, pregnancy testing for females, specialist consultation if prescriber is not board-certified in gastroenterology/hepatology/infectious disease, and patient commitment letter. Set up 2-week dispensing schedule tracking and progress note submission requirements at 8 weeks, completion, and 12 months post-treatment. Claims will be denied without proper prior authorization.