Prior Authorization Request Form - Hepatitis C - Utah Department Of Health printable pdf download

Prior Authorization Request Form - Hepatitis C - Utah Department Of Health

UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM

Direct-acting ant-viral treatments for

Hepatitis C

Patient name:_______________________________________________ Medicaid ID #:_____________________

Prescriber Name:____________________________________________ Prescriber NPI#:____________________

Prescriber Phone#:___________________________________________ Extension/Option:__________________

Prescriber’s office contact person:_______________________________ Prescriber Fax#:____________________

Pharmacy:______________________ Pharmacy Phone#:________________Pharmacy Fax #:_______________

Requested Medication:______________________________Strength:__________Frequency:________________

All information to be legible, complete and correct or form will be returned

___________________________________________________________________________________________

855-828-4992

FAX REQUIRED DOCUMENTATION AND PROGRESS NOTES TO

CRITERIA:

• Diagnosis of Hepatitis C

• Patient must undergo Hepatitis C genotype testing and submit a copy of the testing results. The requested agent

must be FDA-approved to treat the patient’s genotype. FDA-approved genotype indications:

o Daklinza: 1, 3

o Harvoni: 1, 4, 5, 6

o Olysio: 1, excluding 1a

o Sovaldi: 1, 2, 3, 4

o Technivie: 4

o Viekira: 1

o Zapatier: 1a, 1b, 4

• Prescriber is, or has consulted with, an infectious disease physician, hepatologist, gastroenterologist or a

physician assistant or nurse practitioner who practices with an infectious disease physician, hepatologist, or

gastroenterologist.

• Patient shows evidence of at least one of the following:

o fibrosis without hepatic failure

o extrahepatic manifestations

Initial Authorization Period: 12 weeks

Reauthorization: Note that, in many cases, the initial authorization will suffice for a full treatment course. If

continued treatment is desired, please re-submit all of the above and a letter of medical necessity.

03/14/2016

Prior Authorization Request Form - Hepatitis C - Utah Department Of Health