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Epclusa Prior Authorization Resources

Get the latest prior authorization forms for Medicare, Medicaid, and commercial plans, as well as state and medication-specific forms.

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Prior Authorization Forms

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Alluma

Last verified: Apr 15, 2026Alluma - Alluma Prior Authorization Request Form

Amerigroup

Last verified: Apr 15, 2026Amerigroup - Antiviral Agents Hepatitis C Texas Medicaid Prior Authorization Criteria Initial Request

Last verified: Apr 15, 2026Amerigroup - Hepatitis C SVR Reporting Prior Authorization Form Addendum

Last verified: Apr 15, 2026Amerigroup - Antiviral Agents for Hepatitis C Virus Initial Authorization Request (Texas Medicaid)

Last verified: Apr 15, 2026Amerigroup - Hepatitis C Treatments Prior Authorization of Benefits Form (Iowa)

Last verified: Apr 10, 2026Amerigroup - TX Hepatitis C Agents

Anthem, Inc.

Last verified: Apr 15, 2026Anthem - Hepatitis C Antivirals Non-Preferred Prior Authorization Form (Virginia Medicaid)

Arkansas Blue Cross Blue Shield

Last verified: Apr 15, 2026Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form

Blue Cross Blue Shield of Alabama

Last verified: Apr 15, 2026Blue Cross Blue Shield of Alabama - BCBS Alabama Clinical Program Update Prior Authorization

Blue Cross Blue Shield of Illinois

Last verified: Apr 15, 2026Blue Cross Blue Shield of Illinois - Illinois Uniform Prior Authorization Form

Blue Cross Blue Shield of Minnesota

Last verified: Apr 15, 2026Blue Cross Blue Shield of Minnesota - Prior Authorization and Formulary Exception Form

Blue Cross Blue Shield of Rhode Island, Inc.

Last verified: Apr 15, 2026Blue Cross Blue Shield of Rhode Island - Hepatitis C Agents Prior Authorization Request (Prescriber Fax Form)

Blue Cross of Idaho Health Services, Inc.

Last verified: Apr 15, 2026Blue Cross of Idaho - General Prior Authorization Form

California

Last verified: Apr 16, 2026California - Uniform Prior Authorization Form

Capital District Physicians Health Plan, Inc.

Last verified: Apr 15, 2026CDPHP - General Prior Authorization Form

CareFirst, Inc.

Last verified: Apr 15, 2026CareFirst, Inc. - Preauthorization Request Form

Last verified: Apr 15, 2026CareFirst, Inc. - Hepatitis C Prior Authorization Request

Last verified: Apr 15, 2026CareFirst, Inc. - Hepatitis C Step Therapy and Generic Substitution Prior Authorization Request

CareSource Management Group

Last verified: Apr 15, 2026CareSource - Hepatitis C Treatment Prior Authorization Form - Epclusa (Ohio)

Last verified: Apr 10, 2026CareSource - Hepatitis C Prior Authorization Form

Last verified: Apr 10, 2026CareSource - OH MCD Hepatitis C PA Form

Centene Corporation

Last verified: Apr 15, 2026Centene Corporation (South Carolina) - Hepatitis C Prior Authorization Criteria

Cigna Corporation

Last verified: Apr 15, 2026Cigna - General Medication Prior Authorization Form

Last verified: Apr 15, 2026Cigna Corporation - Hepatitis C (Epclusa) Coverage Position Criteria (Non-Preferred Formulary)

Last verified: Apr 15, 2026Cigna Corporation - Hepatitis C (Epclusa) Coverage Position Criteria (National Formulary)

Last verified: Apr 15, 2026Cigna Corporation - Hepatitis C Virus Direct-Acting Antivirals Preferred Specialty Management (National Formulary)

Colorado

Last verified: Apr 16, 2026Colorado - Uniform Prior Authorization Form

Commonwealth of Puerto Rico

Last verified: Apr 15, 2026Commonwealth of Puerto Rico - Epclusa (Sofosbuvir and Velpatasvir) Prior Authorization Form

Curative Health Insurance

Last verified: Apr 15, 2026Curative Health Insurance - Prior Authorization Form

CVS Caremark

Last verified: Apr 15, 2026Caremark - Formulary Exception and Prior Authorization Form

CVS Health (Aetna)

Last verified: Apr 15, 2026Aetna - Illinois Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medicare Prescription Drug Coverage Determination

Last verified: Apr 15, 2026Aetna - Arizona Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Oregon Prior Authorization/Medical Exception/Precertification Form

Last verified: Apr 15, 2026Aetna - Louisiania Prior Authorization Request Form

Last verified: Apr 15, 2026Aetna - Medical Exception/Prior Authorization/Precertification Request for Prescription Medications

Last verified: Apr 15, 2026Aetna - Iowa Prior Authorization/Medical Exception/Precertification Request Form

Last verified: Apr 15, 2026Aetna - California Prior Authorization Form

Last verified: Apr 15, 2026Aetna - Texas Prior Authorization Form

Last verified: Apr 15, 2026Aetna - New Hampshire Prior Authorization Form

Last verified: Apr 15, 2026CVS Health (Aetna) - Hepatitis C Treatment Medication Precertification Request

Department of Veterans Affairs (VHA)

Last verified: Apr 15, 2026Department of Veterans Affairs (VHA) - Sofosbuvir/Velpatasvir (Epclusa) Criteria for Use

District of Columbia

Last verified: Apr 15, 2026District of Columbia - District Epclusa Prior Authorization Form

Florida Agency for Health Care Administration

Last verified: Apr 15, 2026Florida Agency for Health Care Administration - Florida Medicaid Prior Authorization - Hepatitis C Agents Form

Health Partners Plans

Last verified: Apr 15, 2026Health Partners - General Prior Authorization Form

Last verified: Apr 15, 2026Health Partners Plans - HealthPartners Prior Authorization Request for In Network Benefits

Humana, Inc.

Last verified: Apr 15, 2026Humana - General Prior Authorization Form

Illinois

Last verified: Apr 16, 2026Illinois - Uniform Prior Authorization Form

Independent Health Association, Inc.

Last verified: Apr 15, 2026Independence Health - Premium Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Select Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Value Formulary Prior Authorization Form

Last verified: Apr 15, 2026Independence Health - Medicare Part D Pharmacy Prior Authorization Form

Indiana

Last verified: Apr 16, 2026Indiana - Uniform Prior Authorization Form

Kaiser Foundation Health Plans, Inc.

Last verified: Apr 15, 2026Kaiser Permanente of Colorado - Medicare Medication Request form (MRF)

Last verified: Apr 15, 2026Kaiser Permanente of Colorado HMO - Uniform Pharmacy Prior Authorization Request Form

Last verified: Apr 15, 2026Kaiser Permanente - Virginia Medicaid-FAMIS Hepatitis C Agents Prior Authorization Form

Last verified: Apr 15, 2026Kaiser Permanente - Mid Atlantic States HMO Hepatitis C Antivirals Prior Authorization Form

Last verified: Apr 15, 2026Kaiser Permanente - Maryland Health Choice Hepatitis C Treatment Prior Authorization Form

Last verified: Apr 15, 2026Kaiser Foundation Health Plans, Inc. - Virginia Medicaid FAMIS Preferred Drug List

Louisiana

Last verified: Apr 16, 2026Louisiana - Uniform Prior Authorization Form

Louisiana Department of Health Medicaid

Last verified: Apr 15, 2026Louisiana Department of Health Medicaid - Louisiana Medicaid Infectious Disorders - Hepatitis C Direct-Acting Antiviral (DAA) Agents

Maryland Physicians Care (MPC)

Last verified: Apr 15, 2026Maryland Physicians Care - Hepatitis C Prior Authorization Request

Medical Mutual of Ohio Corporation

Last verified: Apr 15, 2026Medical Mutual of Ohio - General Prior Authorization Form

Last verified: Apr 15, 2026Medical Mutual of Ohio - Hepatitis C Virus Direct-Acting Antivirals Preferred Specialty Management

MedImpact

Last verified: Apr 15, 2026MedImpact - MedImpact Prior Authorization Medication Request Form

Last verified: Apr 15, 2026MedImpact - Kentucky Medicaid Preferred Drug List

Last verified: Apr 15, 2026MedImpact - Uniform Prior Authorization Prescription Request

Minnesota

Last verified: Apr 16, 2026Minnesota - Uniform Prior Authorization Form

Molina Health Care, Inc.

Last verified: Apr 15, 2026Molina - Ohio Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Mississippi Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina- Utah Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Utah Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - California Medical Benefit Drug Prior Authorization Form

Last verified: Apr 15, 2026Molina - Idaho Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Wisconsin Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina - Kentucky Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026Molina Health Care - Hepatitis C Agents Refill Prior Authorization Form (Texas Medicaid)

MVP Health Care, Inc.

Last verified: Apr 15, 2026MVP Health Care - NYS Medicaid Pharmacy Prior Authorization Form

Last verified: Apr 15, 2026MVP Health Care - Pharmacy Prior Authorization Form

New York FHSC

Last verified: Apr 15, 2026New York FHSC - NYRx New York Medicaid Pharmacy Program Preferred Drug List

OptumRx

Last verified: Apr 15, 2026OptumRx - Epclusa Prior Authorization Form (TennCare)

Oregon

Last verified: Apr 16, 2026Oregon - Uniform Prior Authorization Form

PacificSource Health Plan

Last verified: Apr 15, 2026Pacific Source - Medicaid Community Solutions Prior Authorization Form

Last verified: Apr 15, 2026Pacific Source - Pharmacy Prior Authorization Form

Premera, Inc.

Last verified: Apr 15, 2026Premera - Pharmacy Prior Authorization Form

Prime Therapeutics

Last verified: Apr 15, 2026Prime Therapeutics - Hepatitis C Direct Acting Antivirals Prior Authorization with Quantity Limit Program Summary

Last verified: Apr 15, 2026Prime Therapeutics - Hepatitis C Direct Acting Antivirals Prior Authorization Request

Providence Health System

Last verified: Apr 15, 2026Providence Health Plan - Drug Prior Authorization Form

Regence BlueShield

Last verified: Apr 15, 2026Regence BlueShield - Regence BlueShield of Idaho Pharmacy Pre Authorization Medication List

State of Iowa

Last verified: Apr 15, 2026State of Iowa - Iowa Medicaid Request for Prior Authorization - Hepatitis C Treatments

State of Kentucky

Last verified: Apr 15, 2026Kentucky Medicaid - Kentucky Medicaid Pharmacy Prior Authorization Form

State of Maryland

Last verified: Apr 15, 2026State of Maryland - Hepatitis C Therapy Prior Authorization Form

State of Montana

Last verified: Apr 15, 2026State of Montana - Epclusa (sofosbuvir and velpatasvir) Drug Summary - Pediatric and Post-Liver Transplant Update

State of North Dakota

Last verified: Apr 15, 2026State of North Dakota - Epclusa Prior Authorization Form

State of Oklahoma

Last verified: Apr 15, 2026State of Oklahoma - Oklahoma Health Care Authority Epclusa Initiation Prior Authorization Form

Last verified: Apr 15, 2026State of Oklahoma - Sofosbuvir/Velpatasvir (Epclusa) Initiation Prior Authorization Form

State of Tennessee

Last verified: Apr 15, 2026State of Tennessee - TennCare Pharmacy Program Preferred Drug List Provider Notice

Texas

Last verified: Apr 16, 2026Texas - Uniform Prior Authorization Form

UnitedHealth Group, Inc.

Last verified: Apr 15, 2026UnitedHealth Group - Hepatitis C Medication Prior Authorization Form (Massachusetts Commercial)

Last verified: Apr 15, 2026UnitedHealth Group - Hepatitis C Direct Acting Antivirals Step Therapy

Last verified: Apr 15, 2026UnitedHealth Group - Epclusa Prior Authorization Medical Necessity

Last verified: Apr 15, 2026UnitedHealth Group - Epclusa Prior Authorization Notification

US Family Health Plan

Last verified: Apr 15, 2026US Family Health Plan - Epclusa Harvoni Sovaldi Zepatier Viekira Prior Authorization Update

Washington

Last verified: Apr 16, 2026Washington - Uniform Prior Authorization Form

WellCare Health Plans

Last verified: Apr 15, 2026WellCare Health Plans - Hepatitis C Treatment Prior Authorization Request

Wellmark Blue Cross Blue Shield

Last verified: Apr 15, 2026Wellmark Blue Cross Blue Shield - Prior Authorization Request Form

Wisconsin

Last verified: Apr 16, 2026Wisconsin - Uniform Prior Authorization Form

See approval requirements for your carrier

Find out what types of documentation and step therapies this carrier may require for coverage.

Check coverage