*Purpose: We describe a multidisciplinary workflow for initiation of hepatitis C virus (HCV) direct-acting antiviral (DAA) therapies post-transplant in the outpatient setting of a high volume transplant program and we highlight the degree of pharmacy involvement for timely initiation of DAAs in a real-world setting.

*Methods: Retrospective chart review was performed, with data abstraction for all solid organ transplant (SOT) recipients of HCV-nucleic acid test (NAT)-positive organs. Date of transplant, treatments prescribed, treatment approval and start dates, and payer information was obtained.

*Results: A standardized institutional pathway was followed for all organ systems, under IRB approval. A multidisciplinary outpatient team including a pharmacist, transplant physician, and transplant infectious diseases physician determine choice of therapy. A prescription is sent to the on-site specialty pharmacy and is processed by a dedicated pharmacy technician. The clinic pharmacist performs comprehensive drug interaction review, medication counseling, and notifies the team when treatment is initiated. Table 1 summarizes treatment details for 73 patients. Prior authorization was required for all but one prescription and 34 prescriptions (45%) needed further appeal. 35% of patients required financial assistance to initiate treatment given copay demands. 1 patient was denied approval for medication despite peer-to-peer review, and our institution supported their complete medication cost, per our protocol. Collating all pharmacy effort, a median estimated 2.8 hours of work per patient was required for a total of 204.5 hours.

*Conclusions: Complex coordination of care and multidisciplinary effort is required for initiating DAA treatment in SOT recipients of HCV NAT-positive organs, even at a high-volume transplant center. Wide variability exists in time from transplant to post-discharge medication initiation, as well as cost. Transplant centers would benefit from awareness of the efforts required for DAA treatment initiation in the outpatient setting.

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