HCV Prescription Drug Prior Authorization Form Form

Page 1 of 2 Revised 12/2016 Form 61-211 PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM Plan/Medical Group Name: ____ Plan/Medical Group Phone#: (___ Plan/Medical Group Fax#: (___) ____ Non-Urgent

Exigent Circumstances

Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization or step-therapy exception request. Information contained in this form is Protected Health Information under HIPAA. Patient Information First Name: Last Name: MI: Phone Number: Address: City: State: Zip Code: Date of Birth: Male Female Circle unit of measure Height (in/cm): __Weight (lb/kg):__ Allergies: Patient’s Authorized Representative (if applicable): Authorized Representative Phone Number: Insurance Information Primary Insurance Name: Patient ID Number: Secondary Insurance Name: Patient ID Number: Prescriber Information First Name: Last Name: Specialty: Address: City: State: Zip Code: Requestor (if different than prescriber): Office Contact Person: NPI Number (individual): Phone Number: DEA Number (if required): Fax Number (in HIPAA compliant area): Email Address: Medication / Medical and Dispensing Information Medication Name: New Therapy
Renewal
Step Therapy Exception Request If Renewal: Date Therapy Initiated:

 Duration of Therapy (specific dates):

How did the patient receive the medication? Paid under Insurance Name: Prior Auth Number (if known): Other (explain): Dose/Strength: Frequency: Length of Therapy/#Refills: Quantity: Administration: Oral/SL Topical Injection IV Other: Administration Location: Physician’s Office Ambulatory Infusion Center Patient’s Home Home Care Agency Outpatient Hospital Care Long Term Care Other (explain): Alameda Alliance for Health (Alliance) 855 ) 508.1713 855 811. __ 9329 __

Page 2 of 2 Revised 12/2016 Form 61-211 PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP THERAPY EXCEPTION REQUEST FORM Patient Name: ID#: Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization or step therapy exception request.

1. Has the patient tried any other medications for this condition? YES (if yes, complete below) NO Medication/Therapy (Specify Drug Name and Dosage) Duration of Therapy (Specify Dates) Response/Reason for Failure/Allergy
2. List Diagnoses: ICD-10:

3. Required clinical information - Please provide all relevant clinical information to support a prior authorization or step therapy exception request review. Please provide symptoms, lab results with dates and/or justification for initial or ongoing therapy or increased dose and if patient has any contraindications for the health plan/insurer preferred drug. Lab results with dates must be provided if needed to establish diagnosis, or evaluate response. Please provide any additional clinical information or comments pertinent to this request for coverage, including information related to exigent circumstances, or required under state and federal laws.
   Attachments Plan/Insurer Use Only: Date/Time Request Received by Plan/Insurer: ____ Date/Time of Decision_ Fax Number (
   ) __ Approved Denied Comments/Information Requested: Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. 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 (via return FAX) and arrange for the return or destruction of these documents. Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form. Prescriber Signature or Electronic I.D. Verification: Date: Patient life expectancy >/= 12 months? Y / N Co-infection? Y / N

   Degree of fibrosis:

   History of cirrhosis? Y / N If yes: Compensated or De-compensated

   Has prescriber addressed all potential drug interactions with prescribed Hepatitis C regimen? Y / N

   Documentation of baseline HCV-RNA level ____ Documentation of HCV genotype __