Background: High costs of direct-acting antivirals (DAAs) have led to their restricted access for patients with hepatitis C virus (HCV). Objective: The aim was to assess how HCV treatment access and predictors of HCV treatment changed in the post-DAA period compared with pre-DAA period. Methods: A retrospective cohort study using Arizona Medicaid data was conducted for patients with HCV to compare treatment initiation rates between pre-DAA (January 2008–October 2013) and post-DAA (November 2013–December 2018) periods. Multivariable logistic regression was used, controlling for demographic and clinical variables. Results: Twenty-four thousand and ninety and 28,756 patients during the pre-DAA and post-DAA periods were identified. Overall, 12.6% were treated in the post-DAA period compared with 7.8% in the pre-DAA period (P<0.001). The relative increase in the HCV treatment initiation rate from the pre-DAA to the post-DAA period was significant greater for Black beneficiaries compared with White beneficiaries (P=0.002). Hispanic beneficiaries were less likely to be treated in the post-DAA period [adjusted odds ratios (aOR): 0.88; CI: 0.79–0.98] compared with White beneficiaries. Those with mental illness (aOR: 0.71; 95% CI: 0.63–0.80) and substance use disorders (aOR: 0.63; 95% CI: 0.58–0.68) were less likely to be treated in the post-DAA period. Conclusions: Although treatment initiation increased and disparities for Black beneficiaries compared with White beneficiaries attenuated in the post-DAA period, only 13% of Arizona Medicaid patients with HCV received DAA treatment. Disparities in DAA access remained among Hispanic patients and those with mental illness and substance use disorders.