Hepatitis C Therapy Prior Authorization Form Page 3

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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 3 of 3
Treatment Plan
Patient’s Name:
DOB:
Genotype (including subtype):
Medications: Please include drugs, dose and duration.
(Take or use medications as directed, do not skip a dose.)
Sovaldi (sofosbuvir) 400mg – Take once daily for
weeks.
Olysio (simeprevir) 150mg – Take once daily for 12 weeks.
Harvoni (sofosbuvir/ledipasvir) 400/90mg – Take once daily for
weeks.
Ribavirin
mg – Take
in the morning and
in the afternoon for
weeks.
Viekira Pak (Ombitasvir/Paritaprevir/Ritonavir/Dasabuvir)
-Take 2 ombitasvir/paritaprevir/ritonavir 12.5/75/50mg tablets once daily
(morning) and 1 dasabuvir 250mg tablet twice daily (morning and evening)
for
weeks.
Peginterferon alfa
_mcg – Inject once weekly for
weeks.
-Take
daily for
weeks.
Laboratory Testing – Indicate week during which labs should be completed.
HCV levels must be obtained at treatment weeks 4, 12 and 24 (if necessary).
Week 2 (if indicated) --
/
/
(please insert due date)
Week 4 --
/
/
(please insert due date)
Week 12 --
/
/
(please insert due date)
Week 24 (if indicated) --
/
/
(please insert due date)
SVR upon completion of therapy
/
/
(please insert due date)
Special Instructions:
Priority Partners, MCO Updated 04.2015

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