*Purpose: Since the advent of direct-acting antiviral (DAA) therapy, use of hepatitis C (HCV) viremic donor organs in HCV negative recipients has become more common. This study aims to capture current practices across the United States.

*Methods: A 40-question survey regarding HCV practices was developed using Qualtrics survey platform (IRB #21-005157). This survey was posted online to members of multiple American Society of Transplantation Community of Practice groups in July 2021.

*Results: There were 39 respondents representing 21 states across the country and Washington, D.C. including pharmacists, advanced practice providers, and nursing. 81% of centers report transplanting viremic organs to aviremic recipients. 59% of centers do not assess insurance coverage for HCV treatment prior to transplant. 9% of centers start DAAs prophylactically; 30% start preemptively at the time of transplant, both with hospital-acquired medication. 53% of respondents reported that their hospital kept DAAs on formulary. However, the majority of centers treat HCV reactively after the recipient becomes viremic. For thoracic organ recipients, 43% of centers use either a 4-or 8-week course of sofosbuvir/velpatasvir (S/V), 42% use 4-or 8-week course of glecaprevir/pibrentasvir (G/P) and 15% unsure. For non-liver abdominal organ recipients, 32% used G/P for 8 weeks, 26% used G/P for 12 weeks, and 16% used S/V for 12 weeks, 5% used G/P for 4 weeks and 21% unsure or other. For liver recipients, 35% used G/P for 12 weeks, 18% used G/P for 8 weeks, 18% used S/V for 12 weeks, 5% used G/P for 4 weeks and 24% unsure or other, including S/V for 8 weeks. Most transplant centers do not pay for the full course of HCV treatment, though 26% of centers financially cover the initial inpatient course, followed by insurance coverage for the remainder of treatment. 58% of centers have a safety mechanism in place for covering HCV treatment without insurance approval. Pharmacists and pharmacy staff typically complete the majority of prior authorization and appeal paperwork, spending 1-4 hours on each case. 16% of centers reported that insurance denied DAA after transplantation even after prior authorization request and appeal. 71% of centers reported that their transplant recipients required additional grant assistance to pay for treatment.

*Conclusions: HCV therapy after transplant requires significant financial and resource utilization. There is multicenter variability regarding payer status, treatment strategy and treatment regimens for expected donor-derived HCV infection.

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