Fillable MERCY CARE (MEDICAID) Hepatitis C Medications d in (Mercy Care)

Fill Online, Printable, Fillable, Blank MERCY CARE (MEDICAID) Hepatitis C Medications d in (Mercy Care) Form

Use Fill to complete blank online MERCY CARE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MERCY CARE (MEDICAID) Hepatitis C Medications d in (Mercy Care)

On average this form takes 15 minutes to complete

The MERCY CARE (MEDICAID) Hepatitis C Medications d in (Mercy Care) form is 3 pages long and contains:

  • 1 signature
  • 23 check-boxes
  • 47 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Mercy Care forms online.

BROWSE MERCY CARE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Pharmacy Prior Authorization
MERCY CARE (MEDICAID)
Hepatitis C Medications
This fax machine is locate
d in a secure location as required by HIPAA regulations. Complete/review information,
sign and date. Fax signed forms to Mercy Care at 1-800-854-7614
. Please contact
Mercy Care
at
1-800-624-3879
with questions regarding the prior
authorization process. Please note that all authorization requests will be
reviewed as the AB rated generic (when available) unless states otherwise.
Prior authorizati
on for hepatitis C treatment requires submission of medical records with the prior
authorization request. Incomplete and/or illegible request forms may result in a denial including those
without medical records.
Requested Treatment Regimen (Check all medications requested):
Mavyret
Sovaldi
Vosevi
Epclusa
Viekira Pak
Harvoni
Zepatier
O
ther: Please specify_
___________________________
Treatment Duration:
8 weeks 12 weeks 16 weeks 24 weeks Other (please specify) __________________________________
Patient Information
Patient Name:
____________________________________
_________________________________
Patient Phone #:
Member ID #:
___________________________________
Patient DOB:
_________________________________
Prescriber Information
Prescriber’s Name:
_________________________________
_________________________________
Prescriber’s E-mail:
_________________________________
___________________________________
Prescriber’s NPI:
___________________________________
________________________________
Office Contact Name:
Office Phone:
Office Fax:
Office Address:
_______________________________
City/State/ZIP:
_________________________________
Criteria for Approval
Decisions are based on Mercy Care Prior Authorization Criteria Policy which may be found at:
Mercy Care Plan Pharmacy Guidelines
Please answer all required questions below and provide relevant supporting information including medical records
1.
Does the patient meet ALL the following treatment requirements?
a) Age is equal to or greater than 12 years
b) Diagnosis of Hepatitis C infection confirmed by detectable serum HCV RNA quantitative
assay within last 90 days, HCV genotype, viral resistance status (when applicable),
hepatic status (Child-Pugh Score), and HCV viral load
c) Member has been screened for Hepatitis A and B, and must have received at least one
Hepatitis A, and at least one Hepatitis B vaccine, prior to requesting treatment, unless
member demonstrates laboratory evidence of immunity
d) Retreatment Requests only: Member was adherent to previous DAA therapy as
evidenced by medical records and/or pharmacy prescription claims. If prior therapy
Yes No
Effective: 04/01/2020 C15561-A Page 1 of 3
Proprietary
was discontinued due to adverse effects from DAA, medical records must be provided
which documents these adverse effects, and recommendation of discontinuation by
treatment provider
2.
Is treatment prescribed by, or in consultation with gastroenterologist, hepatologist or
infectious disease physician? Yes No
3.
Does the patient have ANY of the following treatment exclusions?
a) Life expectancy is less than 12 months and cannot be remediated by treating HCV
infection, by transplantation, or by other directed therapy
b) Member was non-adherent to initial DAA treatment regimen as evidenced by medical
records and/or pharmacy prescription claims
c) Member declines to participate in a treatment adherence program
d) Member declines to participate in a substance abuse disorder treatment program
e) Substance abuse activity within 3 months from date of request for HCV treatment
f) History of substance use disorder within past 12 months, without evidence of remission
during most recent 3 months
g) Current use of potent P-gp inducer (St. John’s wart, rifampin,
carbamazepine, ritonavir, tipranavir, etc.)
h) Retreatment request is for more than one retreatment with a DAA, and requested
retreatment regimen includes more than one DAA
i) Direct acting antiviral dosages greater than FDA-approved maximum dosage
j) Coverage is for greater than duration of treatment outlined in tables within guideline.
k) Lost or stolen medication, or fraudulent use.
l) Request for Viekira Pak, Mavyret, and Zepatier in members with Child-Pugh B or C
m) Requests for Zepatier, if NS5A polymorphism testing has not been completed and
submitted with prior authorization request
n) Sovaldi used as monotherapy
o) Use in combination with other direct-acting antivirals (DAAs) unless indicated
p) Patient has contraindication to any of the agents
Yes No
The patient’s treatment status (circle one):
Treatment Naïve Treatment Experi
enced Status Post Transplant
Prior Hepatitis C Treatments (check all applicable):
Incivek
Victrelis Olysio peginterferon ribavirin Sovaldi Harvoni Viekira Pak
Daklinza Technivie Epclusa Viekira XR Zepatier Mavyret Vosevi
Does prescriber agree to submit required documentation?
Yes No
HCV viral load laboratory results must be submitte
d to Contractor/PBM at 12 and 24 weeks post
therapy completion to demonstrate Sustained Virologic Response (SVR)
Patient readiness has been assessed, and patient attestation of compliance is submitted, and on
file in member’s medical record (prescribers shall u se the CSPMP as a tool to aid in review of
compliance)
1
Member agrees to complete the regimen and understands the risks of reinfection and other
contributors to liver disease and/or damage, through a signed attestation
Provider agrees to monitor hemoglobin levels periodically if member i
s prescribed ribavirin
1
POST TCN/PC Change Added to require a record of the member’s agreement to comply with the treatment
Effecti
ve: 04/01/2020 C15561-A Page 2 of 3
Proprietary
______________________________________________________ ___________________________
Diagnosis / Dosing (all sections required)
Diagnosis (include ICD9 Code):
___________________________
Genotype:
1
2 3 4 5 6
(must submit lab results completed within 90
days of prior authorization request)
NS5A polymorphism:
28
30
31
93
Viral Load (HCV-RNA):
(must submit lab results completed
within 90 days of prior authorization
request)
______________________________
Please circle Child Pugh Score(required) and submit supporting documentation with request:
Child Pugh Score
CPT A CPT B CPT C
Additional Information:
By signing, the prescribing or authorizing clinician is attesting that information on this form is accurate as of this date,
and that documentation supporting above information is recorded in patient’s medical chart. Requests for Hepatitis C
medications must be submitted with supporting medical records.
Prescriber (Or Authorized) Signature Date
Effective: 04/01/2020 C15561-A Page 3 of 3
Proprietary
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MERCY CARE (MEDICAID) Hepatitis C Medications d in (Mercy Care)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document