Harvoni (Ledipasvir / Sofosbuvir) Prior Authorization Of Benefits (Pab) Form (Page 2 of 2) in pdf

CONTAINS 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

PATIENT NAME: ________________________________ PATIENT ID #: _____________________________________

□

Yes

Patient is using Harvoni in combination with ribavirin for one of the following antiviral treatment

regimens (please indicate):

□

Patient is dual (interferon and ribavirin) or triple [interferon, ribavirin, and NS3 HCV protease

inhibitor (Olysio, Incivek, or Victrelis)] treatment-experienced with compensated cirrhosis, eligible

for ribavirin, and Genotype 1

□

Patient is dual (sofosbuvir and ribavirin or sofosbuvir and simeprevir) or triple (interferon, ribavirin,

and sofosbuvir) treatment-experienced with or without compensated cirrhosis and Genotype 1

□

Patient treatment-naïve or treatment-experienced (interferon and ribavirin or interferon, ribavirin,

and a NS3 HCV protease inhibitor), post-liver allograft transplant recipient with HCV Genotypes 1

or 4 and compensated liver disease with or without cirrhosis or decompensated cirrhosis

□

Yes

Patient has severe renal impairment (CrCl less than 30 mL/min), end stage renal disease, or

requires dialysis

□

Yes

Patient is requesting concurrent therapy with contraindicated or not recommended agents, such as

but not limited to the following: amiodarone, carbamazepine, phenytoin, phenobarbital,

oxcarbazepine, rifabutin, rifampin, rifapentine, elvitegravir/cobicistat/emtricitabine/tenofovir DF,

tepranavir/ritonavir, St John’s Wort, or rosuvastatin

□

Yes

Patient is using sofosbuvir/ledipasvir in combination with a non-nucleoside NS5B inhibitor (such as

but not limited to dasabuvir) oranother nucleotide NS5B polymerase inhibitor [such as Sovaldi

(sofosbuvir)]

□

Yes

Patient is using sofosbuvir/ledipasvir in combination with another NS5A inhibitor [such as but not

limited to, Daklinza (daclatasvir) or ombitasvir]

□

Yes

Patient is using Harvoni in combination with a NS3/4A protease inhibitor [such as but not limited to,

Olysio (simeprevir), Incivek (telaprevir), Victrelis (boceprevir) or paritaprevir]

□

Yes

Patient is requesting the regimen for re-treatment and either failed to achieve a SVR (defined as a

lower limit HCV RNA of 25 IU/mL) or relapsed after achieving a SVR during a prior successfully

completed treatment regimen consisting of ledipasvir

□

Yes

Patient is 18 years of age or older

Please indicate patient’s Genotype: _________

□

Yes

Patient is treatment naïve

□

Yes

Patient is dual treatment-experienced, with prior sofosbuvir regimen

□

Yes

Patient is triple treatment-experienced, with prior sofosbuvir regimen

□

Yes

Patient has compensated cirrhosis

□

Yes

Patient has decompensated cirrhosis

□

Yes

Patient is eligible for ribavirin

□

Yes

Patient is post-liver allograft transplant

□

Yes

Patient has a baseline HCV RNA level of less than 6 million IU/mL

□

Yes

Patient has cirrhosis

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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Harvoni (ledipasvir / sofosbuvir) NTL PAB Fax Form 01.01.16.doc