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Download Priority Health Medicare Prior Authorization Form: Technivie
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Transcript
Priority Health Medicare prior authorization form Fax completed form to: 877.974.4411 toll free, or 616.942.8206 Medicare Part B Expedited request This form applies to: This request is: Medicare Part D Standard request Your request will be expedited if you haven’t gotten the prescription and Priority Health Medicare determines, or your prescriber tells us, that your life or health may be at risk by waiting. Technivie™ (ombitasvir/paritaprevir/ritonavir) Reset Form Member Last Name: ID #: Primary Care Physician: First Name: DOB: Gender: Requesting Provider: Provider Address: Provider NPI: What is the provider’s specialty? Prov. Phone: Prov. Fax: Contact Name: Gastroenterologist Hepatologist Infectious disease specialist Other: Provider Signature: Date: Drug information Drug product: Technivie 12.5 mg-75 mg-50 mg Start date (or date of next dose): Date of last dose (if applicable): Dosing frequency: Prior authorization criteria The following requirements need to be met before this drug is covered by Priority Health Medicare. These requirements have been approved by the Centers for Medicare and Medicaid Services (CMS), but you may ask us for an exception if you believe one or more of these requirements should be waived. 1. 2. 3. 4. 5. 6. Prescriber must be a gastroenterologist, hepatologist, or infectious disease specialist Age 18 or older Must have chronic hepatitis C genotype 4 infection without cirrhosis Must first try Harvoni Must be taken with ribavirin for genotype 4 unless patient is ineligible to take ribavirin because of a contraindication or intolerance The approved duration of treatment is: Genotype 4 Description of patient’s condition Treatment-naïve without cirrhosis Treatment-experienced without cirrhosis Duration of treatment 12 weeks 12 weeks Technivie is not recommended in patients with moderate hepatic impairment (Child-Pugh B). Technivie is contraindicated in patients with severe hepatic impairment (Child-Pugh C). Page 1 of 3 All fields must be complete and legible for review. Your office will receive a response via fax. Updated 09/2015 Last reviewed 11/2016 Medically accepted indication This drug is only covered under Medicare Part D when it is used for a medically accepted indication. A medically accepted indication is a use of the drug that is either: approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.) –– or –– supported by certain reference books. (These reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and the USPDI or its successor.) Priority Health Precertification Documentation A. What condition is this drug being requested for? Chronic hepatitis C infection Other – the patient’s condition is: B. What is the patient’s HCV genotype? 1a 1b 2 3 4 5 6 C. For patients with genotype 4, will he or she also use ribavirin? Yes No If no, does the patient have intolerance to ribavirin? No Yes, the intolerance is: disabling flu-like symptoms (fever, rigors, severe myalgia, nausea/vomiting) lasting more than 24 hours severe, unstable psychiatric disease under treatment hemolytic anemia local/systemic severe adverse reaction (e.g. cardiovascular, pancreatitis, new onset psychiatric disease, musculoskeletal, infection). If a different reason interferon cannot be used, explain why: D. Does the patient have hepatic impairment? Yes: Moderate (Child-Pugh B) Severe (Child-Pugh C) No E. Has the patient first tried Harvoni? Yes, for _________ weeks from ______________________________________ (list dates) No, because Page 2 of 3 All fields must be complete and legible for review. Your office will receive a response via fax. Updated 09/2015 Last reviewed 11/2016 Priority Health Medicare exception request Do you believe one or more of the prior authorization requirements should be waived? Yes No If yes, you must provide a statement explaining the medical reason why the exception should be approved. Would Technivie likely be the most effective option for this patient? No Yes, because: If the patient is currently using Technivie, would changing the patient’s current regimen likely result in adverse effects for the patient? No Yes, because: Page 3 of 3 All fields must be complete and legible for review. Your office will receive a response via fax. Updated 09/2015 Last reviewed 11/2016