Form Gl2430 - Group Benefits Prior Authorization - Hepatitis C Therapy - 2016
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1
2GROUP BENEFITS
PRIOR AUTHORIZATION FORM
HEPATITIS C THERAPY
INSTRUCTIONS
Mail: Co-operators Life Insurance Company
Extended Health Care Claims
1920 College Avenue
Regina, SK S4P 1C4
Fax:
(306) 761-7101
PART 1 - PATIENT INFORMATION
Group _________________________________
Account _______________________________________ Certificate _______________________________________
Plan Member ______________________________________________________ _______ _______________________________________________________________
First Name
Initial
Last Name
Patient ____________________________________________________________ _______ _______________________________________________________________
First Name
Initial
Last Name
Address ____________________________________________________________ ___________________________________________ ________ ___________________
Street
City
Province
Postal Code
Date of Birth ____________________________
Relationship to Plan Member _________________________________________________________________________
MMM/DD/YYYY
PART 2 - PHYSICIAN INFORMATION
Physician _______________________________________ _____ _______________________________________
Specialty ____________________________________
First Name
Initial
Last Name
Address ____________________________________________________________ ___________________________________________ ________ ___________________
Street
City
Province
Postal Code
Telephone Number ( ________ ) __________________________ Fax Number ( ________ ) __________________________
Select the requested drug and provide DIN and required Strength:
Name
DIN
Strength
Name
DIN
Strength
Sovaldi
Galexos
Harvoni
Incivek
Daklinza
Ibavyr
Victrelis
Holkira Pak
Victrelis Triple
Technivie
Other: _________________
Expected Duration of Therapy _______________________________
Dosing Regimen _______________________ Anticipated Monthly Cost $ ________________
Date of Diagnosis _____________________________ Hepatitis C Genotype ___________________________________________________________________________
1.
Treatment Naïve?
.................................................................................................................................................................................................
Yes
No
If no, please fill out drug history:
Drugs past and present, dosing regimen, start date, end date, response to therapy (null/partial/relapse) ____________________________
_____________________________________________________________________________________________________________________
2.
Patient has detectable Hepatitis C RNA within the last 6 months?
.......................................................................................................................
Yes
No
3.
Patient has advanced fibrosis documented by liver biopsy-proven fibrosis staging score of F3 or F4 (METAVIR Scale)?
......................................
Yes
No
4.
Patient is a liver transplant recipient?
...................................................................................................................................................................
Yes
No
If yes, provide details of where and when _________________________________________________________________________________
5.
Patient has Type 2 or 3 essential cryoglobulinemia present with end-organ manifestations?
................................................................................
Yes
No
If yes, provide documentation __________________________________________________________________________________________
6.
Glomerular disease present?
...............................................................................................................................................................................
Yes
No
If yes, describe and provide documentation _______________________________________________________________________________
7.
Patient has compensated liver disease (Child Pugh score <6)?
...........................................................................................................................
Yes
No
8.
Patient has extrahepatic manifestations of Hep C infection?
................................................................................................................................
Yes
No
If yes, describe and provide documentation _______________________________________________________________________________
I hereby certify that the information provided in this request is true, complete and accurate.
Signature of Physician _________________________________________________________________________________
Date _________________________________
MMM/DD/YYYY
CO-OPERATORS LIFE INSURANCE COMPANY
GL2430 (01/16)
1920 COLLEGE AVENUE REGINA SK S4P 1C4
PG 1 of 2
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