Harvoni (Ledipasvir / Sofosbuvir) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Harvoni (ledipasvir / sofosbuvir)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: __________________________________
Prescribing Physician: ____________________________
Patient ID #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
____________
Harvoni (ledipasvir / sofosbuvir)
______________________
Specify: _________________
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
□
□
Yes
No
Patient has a diagnosis of chronic hepatitis C (CHC) infection
□
□
Documentation of the patient’s diagnosis has been provided with this request, which includes
Yes
No
genotype and a persistent positive HCV RNA test result for at least 6 months following positive
baseline result
□
□
Yes
No
A copy of the baseline quantitative hepatitis C virus (HCV) RNA test results is provided to document
baseline level of viremia
□
□
Yes
No
Patient has a short life expectancy (less than 12 months owing to non-liver related comorbid
conditions) that cannot be remediated by treating HCV, by transplantation or other directed therapy
□
□
Yes
No
Patient has genotype 1, 4, 5, or 6 and compensated liver disease (with or without cirrhosis)
□
□
Yes
No
Patient has genotype 1 or 4 and decompensated liver disease with cirrhosis following allograft
liver transplantations
□
□
Yes
No
Patient is actively abusing illicit drugs and/or alcohol
□
□
Yes
No
Patient is receiving concurrent treatment to facilitate cessation of drug and/or alcohol abuse
□
□
Yes
No
Patient is using Harvoni as monotherapy for one of the following antiviral treatment regimens (please
indicate):
□
Patient is treatment-naïve, dual (interferon and ribavirin) treatment-experienced, or triple
[interferon, ribavirin, and NS3 HCV protease inhibitor (Olysio, Incivek, or Victrelis)] treatment-
experienced with or without compensated cirrhosis and genotype 1
□
Patient is treatment-naïve, dual (interferon and ribavirin) treatment-experienced, or triple
[interferon, ribavirin, and HS3 HCV protease inhibitor (Olysio, Incivek, or Victrelis)] treatment-
experienced with or without compensated cirrhosis and Genotype 4
□
Patient is treatment-naïve, ribavirin intolerant/ineligible (such as but not limited to, pregnant
women, hemoglobinopathies), with or without compensated cirrhosis, and a post-liver allograft
transplant recipient with HCV Genotypes 1 or 4
□
Patient is treatment-naïve, dual (interferon and ribavirin) treatment-experienced, or triple
[interferon, ribavirin, and NS3 HCV protease inhibitor (Olysio, Incivek, or Victrelis)] treatment-
experienced with or without cirrhosis and Genotype 5 or 6
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Harvoni (ledipasvir / sofosbuvir) NTL PAB Fax Form 01.01.16.doc
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