Hepatitis C Therapy Prior Authorization Form
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3Fill ONLY at Delmarva Pharmacy - NPI#- 1194768473
1. Complete all 3 (three) pages of this form. Incomplete forms will be returned.
2. Attach required genotype results and biopsy results or other fibrosis test results.
3. Return form and supporting documentation to 410-424-4607 or 410-424-4751.
4. Questions? Contact PP Pharmacy Review at 888-819-1043, option 4.
Hepatitis C Therapy Prior Authorization Form: Page 1 of 3
Member Information:
PPMCO#:
Name:
MEDICAID #:
DOB:
SEX:
BODY W EIGHT
lb. or
KG
MEMBER PHONE#:
PATIENT LOCATION:
Home
Hospital
Clinic
Diagnosis (Attach genotype test results):
Acute Hep C
Chronic Hep C
Genotype of pre-transplant liver:
Hepatocellular Carcinoma
Genotype of post-transplant liver:
What is patient’s HCV genotype (including subtype)?
Has a liver biopsy been performed?
Yes
Test Date:
/
/
No
Provide a copy of biopsy results or other fibrosis test. Specify Metavir grade:
Stage:
Hepatitis C Patient Characteristics
This request is for:
New Therapy
Relapser
Partial Responder
Decompensated liver d/s
Non-responder
Compensated cirrhosis (treatment naïve or experienced)
No cirrhosis
Drug Regimen Requested
Sovaldi®: ________ ________ ________
Olysio®: ________ ________ ________
Strength
Dose
Duration
Strength
Dose
Duration
Pegylated ________ ________ ________
Viekira Pak™: ________ ________ ________
Strength
Dose
Duration
Interferon Strength
Dose
Duration
Harvoni®: ________ ________ ________
Viekira Pak™: ________ ________ ________
Strength
Dose
Duration
Strength
Dose
Duration
Viekira Pak™: ________ ________ ________
Strength
Dose
Duration
Anticipated Total Treatment Duration:
Adherence with prescribed therapy is a condition for payment and continuation therapy up to
the allowed timeframe for each HCV Genotype. The recipient’s Medicaid drug history will be
reviewed prior to approval.
Has drug therapy plan been developed and discussed with patient?
Yes
No
Laboratory Results:
Has a test been performed for the Q80K polymorphism?
Yes Test Date:
/
/
No
Baseline HCV RNA level (within 45 days pre-treatment):
log 10
Test Date:
/
/
Follow up labs:
HCV
*HCV RNA level between 2 to 4 weeks will be accepted
RNA level at treatment week 4*:
log10
Measurement Date:
/
/
HCV RNA level at treatment week 12:
log10
Measurement Date:
/
/
HCV RNA level at treatment week 24:
log10
Measurement Date:
/
/
Priority Partners, MCO Updated 04.2015
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