Victrelis (Boceprevir) Prior Authorization Of Benefits (Pab) Form (Page 2 of 2) in pdf

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Victrelis (boceprevir)

Prior Authorization of Benefits (PAB) Form

Complete form in its entirety and fax to:

Prior Authorization of Benefits Center at (800) 601- 4829

Patient Name: ___________________________________

Patient ID#: __________________________________

□

Yes

The request is for continued therapy

If Yes:

□

Yes

No Patient has HCV-RNA results greater than or equal to 1000 IU/mL at treatment

week 8 (If yes, discontinue therapy with Victrelis)

□

Yes

No Patient has HCV-RNA results greater than or equal to 100 IU/mL at treatment

week 12 (If yes, discontinue therapy with Victrelis)

□

Yes

No Patient has confirmed, detectable HCV-RNA at treatment week 24 (If yes,

discontinue therapy with Victrelis)

The patient’s HVC Treatment Status is:

□

Previously untreated with HCV RNA Results at treatment week 8 of Not Detected

□

Previously untreated with HCV RNA Results at treatment week 8 of Detected

□

Previous partial responder or relapse

□

Previous null responder

If the individual has HCV-RNA levels of greater than or equal to 1000 IU/mL at treatment week 8, then discontinue

therapy with Victrelis.

If the individual has confirmed, detectable HCV-RNA at treatment week 12, then discontinue therapy with

Victrelis.

If the individual has confirmed, detectable HCV-RNA at treatment week 24, then discontinue therapy with

Victrelis.

9. PHYSICIAN SIGNATURE

____________________________________________________________

__________________________________________

Prescriber or Authorized Signature

Date

Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what

medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting

provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.

Note: Payment is subject to member eligibility. Authorization does not guarantee payment.

The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only

for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other

party unless required to do so by law or regulation.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of

these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or

destruction of these documents.

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Victrelis NTL PAB Fax Form 04.23.15.doc