Prior Authorization Form - South Carolina Pharmacy Services

Prior Authorization Form
Hepatitis C- Antiviral Agents
Access this PA form at http://southcarolina.fhsc.com/providers/rxdocuments.asp
If the following information is not complete, correct, or legible, the PA process can be delayed. Use one form per member please.
Member Information
LAST NAME:
FIRST NAME:
ID NUMBER:
DATE OF BIRTH:
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Prescriber Information
LAST NAME:
FIRST NAME:
NPI NUMBER:
DEA NUMBER:
PHONE NUMBER:
FAX NUMBER:
–
–
Clinical Criteria Documentation
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–
****Do not include documentation that is not requested on this form****
***Complete Chart & attach documentation of lab values***
Laboratory Documentation
Baseline HCV RNA level
Week 4 HCV RNA level
Week 12 HCV RNA level
1.
What is the diagnosis for which this drug is being requested?
Chronic Hepatitis C, genotype 1a
Chronic Hepatitis C, genotype 1b
Other _______________________________________________
2.
For females: Is the patient pregnant?
3.
Please check if the patient has any of the following. If yes, documentation must be attached.
Yes
No
Yes
No
Yes
No
Liver biopsy showing Metavir score of F3/F4
Fibrotest (FibroSure) score of ≥ 0.59
Ultrasound based transient elastography (Fibroscan) score ≥ 9.5 kPa
Fibrosis-4 index (FIB-4) > 3.25
4.
Please check if the patient has any of the following. If yes, documentation must be attached.
Essential mixed cryoglobulinemia with end organ manifestations
Proteinuria
Nephrotic Syndrome
Membranoproliferative glomerulonephritis
5.
Has the patient had prior treatment with dasabuvir/ombitasvir/paritaprevir?
Yes
No
6.
Is patient taking concomitant therapy with a hepatitis C protease inhibitor?
Yes
No
This facsimile transmission contains legally privileged and confidential information intended for the parties identified below.
If you have received this transmission in error, please immediately notify us by telephone and return the original message to
SC Medicaid Pharmacy Program, c/o Magellan Health Services, 1103 Broad Street, Suite 500, Glen Allen, VA23060.
Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.
© 2014, Magellan Health Services, Inc. All Rights Reserved.
Prior Authorization Form
Hepatitis C- Antiviral Agents
Access this PA form at http://southcarolina.fhsc.com/providers/rxdocuments.asp
7.
Is the patient actively participating in illicit substance or alcohol abuse?(If Yes, Skip to Question#11)
Yes
No
Yes
No
Does the patient have a past history of illicit substance or alcohol abuse?
• If yes, attach confirmation that the patient has completed or is participating in a recovery
program, or receiving substance or alcohol abuse counseling services, or seeing an addiction
specialist as part of Chronic Hepatitis C treatment
Yes
No
Has the patient been free of substance abuse for the previous 6 months?
Yes
No
10. Has the patient been free of alcohol abuse for the previous 6 months?
Yes
No
11. Does the patient have decompensated cirrhosis, defined as a Child-Pugh score of greater than 6
(Class B or C)?
Yes
No
12. Does the patient have a diagnosis of compensated cirrhosis?
Yes
No
13. Will the patient be taking in combination with ribavirin?
Yes
No
15. Is the patient taking concomitant therapy with any of the following contraindicated medications? If
yes, please provide documentation: chart notes, claims history, or statement attesting to current
therapy
alfuzosin, carbamazepine, phenytoin, phenobarbital, gemfibrozil, rifampin, ergotamine,
dihydroergotamine, ergonovine, methylergonovine, ethinyl estradiol-containing contraceptives, St.
John’s wort, lovastatin, simvastatin, pimozide, efavirenz, sildenafil (when dosed for the treatment
of pulmonary arterial hypertension), triazolam, orally administered midazolam
Yes
No
16. Is the patient taking concomitant therapy with any of the following potentially significant
interacting medications? If yes, please provide supporting documentation: chart notes, claims
history, or statement attesting to current therapy (for Viekira):
Antiarrythmics: amiodarone, bepridil, disopyramide, flecainide, lidocaine (systemic),
mexiletine, propafenone, quinidine
Antifungals: ketoconazole, voriconazole
Calcium Channel Blockers: amlodipine
Corticosteroids: fluticasone
Diuretics: furosemide
HMG CoA Reductase Inhibitors: rosuvastatin, pravastatin
Immunosuppressants: cyclosporine, tacrolimus
Narcotic Analgesics: buprenorphine
Sedatives/Hypnotics: alprazolam
Proton Pump Inhibitors: omeprazole
HIV Antivirals: atazanavir/ritonavir, darunavir/ritonavir, lopinavir/ritonavir, rilpivirine
Long acting beta-agonists: salmeterol
Yes
No
.
8.
9.
14. Please check the box corresponding to the specialty of the prescribing physician:
Gastroenterologist
Hepatologist
Infectious Disease Specialist
Other ______________________________________________________________________
This facsimile transmission contains legally privileged and confidential information intended for the parties identified below.
If you have received this transmission in error, please immediately notify us by telephone and return the original message to
SC Medicaid Pharmacy Program, c/o Magellan Health Services, 1103 Broad Street, Suite 500, Glen Allen, VA23060.
Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.
© 2014, Magellan Health Services, Inc. All Rights Reserved.
Prior Authorization Form
Hepatitis C- Antiviral Agents
Access this PA form at http://southcarolina.fhsc.com/providers/rxdocuments.asp
17. Is the patient taking concomitant therapy with any of the following potentially interacting
medications? If yes, please provide supporting documentation: chart notes, claims history or
statement attesting to current therapy. (For Harvoni):
• Acid Reducing Agents: antacids, PPIs, H2Blockers
• Antiarrhythmics: digoxin
• HIV Antiretroviral combinations including tenofovir
• HCV products: simeprevir
• Anticonvulsants: carbamazepine, phenytoin, phenobarbital, oxcarbazepine
• Antimycobacterials: rifabutin, rifampin, rifapentine
• HIV medications: tipranavir/ritonavir, cobicistat/elvitegravir/emtricitabine/tenofovir
• Herbal Supplements: St John’s wort
• HMG-CoA Reductase Inhibitors: rosuvastatin
18. Which of the following best describes the patient prior to this course of treatment for hepatitis C?
Treatment naïve
Prior “null responder” (less than a 2 log decrease in HCV-RNA at treatment week 12)
Prior relapser (undetectable HCV RNA at end of previous treatment, but detectable within 24
weeks after treatment)
Prior partial responder (≥ 2 log decrease in HCV RNA at week 12 of previous treatment, but did
not achieve undetectable HCV RNA at end of treatment)
19. Preferred Products
(ombitasvir/paritaprevir/ritonavir and dasabuvir (Viekira Pak™) 12.5.75/50mg and 250mg tabs
ribavirin (if patient is unable to take ribavirin, clinical documentation must be included)
Non-Preferred Products
sofusbuvir (Sovaldi ®) 400mg tab
simeprevir (Olysio®) 150mg cap
ledipasvir/sofosbuvir (Harvoni®) 90-400mg tab
This facsimile transmission contains legally privileged and confidential information intended for the parties identified below.
If you have received this transmission in error, please immediately notify us by telephone and return the original message to
SC Medicaid Pharmacy Program, c/o Magellan Health Services, 1103 Broad Street, Suite 500, Glen Allen, VA23060.
Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.
© 2014, Magellan Health Services, Inc. All Rights Reserved.
Yes
No
Prior Authorization Form
Hepatitis C- Antiviral Agents
Access this PA form at http://southcarolina.fhsc.com/providers/rxdocuments.asp
Please note any other information pertinent to this PA request:
Please Note: If approved, compliance with therapy is required. Authorizations will be terminated for patients who are noncompliant
with therapy.
Prescriber Signature (Required)
(**On behalf of the Prescriber or Pharmacy Provider, I **certify that the information stated above is a true
statement, made for the purposes of inducing SC Medicaid to offer prescription coverage to this individual
for the medication requested above. I understand that this document and any attached materials will be
RETAINED FOR THE PURPOSES OF POSSIBLE FUTURE AUDIT).
Fax This Form to: 888-603-7696
Phone: 866-247-1181
PA’s may be requested online, see the following website for details:
http://southcarolina.fhsc.com/
This facsimile transmission contains legally privileged and confidential information intended for the parties identified below.
If you have received this transmission in error, please immediately notify us by telephone and return the original message to
SC Medicaid Pharmacy Program, c/o Magellan Health Services, 1103 Broad Street, Suite 500, Glen Allen, VA23060.
Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.
© 2014, Magellan Health Services, Inc. All Rights Reserved.
Date