Ribavirin (Medicare Prior Authorization)

Transcription

1 Prior Authorization Form ARKANSAS BLUE CROSS AND BLUE SHIELD Medi-Pak Rx (PDP), Medi-Pak Advantage (PFFS), and Medi-Pak Advantage PPO Ribavirin (Medicare Prior Authorization) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CVS/Caremark at Please contact CVS/Caremark at with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Ribavirin (Medicare Prior Authorization). Drug Name (select from list of drugs shown) RibaPak (ribavirin tablet) Ribasphere (ribavirin capsule) Ribasphere Tablet (ribavirin) Ribavirin capsule Ribavirin tablet Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: Please circle the appropriate answer for each question. ICD Code: 1. Does the patient have any of the following contraindications to ribavirin therapy? Hemoglobin less than 8.5 g/dl \ Diagnosis of a hemoglobinopathy (e.g., thalassemia major or sickle-cell anemia) \ History of unstable heart disease (e.g., coronary artery disease, heart failure) 2. Does the patient meet one of the following: Have a creatinine clearance (CrCl) greater than or equal to 50 ml/min \ Have a CrCl less than 50 ml/min but will use reduced dose of ribavirin 3. Has or will the patient be instructed to practice effective contraception during therapy and for 6 months after stopping ribavirin therapy? 4. Is the patient or the partner of the patient pregnant?

2 5. Is ribavirin prescribed by or in consultation with one of the following specialists? Infectious disease specialist \ Gastroenterologist \ Oncologist 6. Prior to initiating therapy, did the patient have a diagnosis of chronic hepatitis C virus (HCV) infection as confirmed by presence of HCV RNA (a viral load) in the serum? 7. Is the patient prescribed Victrelis or has the patient received Victrelis as part of current treatment course? [If yes, skip to question 30.] 8. Is the patient prescribed Incivek or has the patient received Incivek as part of current treatment course? [If yes, skip to question 44.] 9. Is ribavirin requested for RETREATMENT of HCV? [If no, skip to question 17.] 10. Is the patient currently receiving therapy for RETREATMENT? [If yes, skip to question 22.] 11. Is the patient prescribed ribavirin in combination with pegylated interferon (Pegasys or PegIntron)? [If no, skip to question 14.] 12. Has the patient had a nonresponse or relapse with prior HCV therapy? RELAPSE: Patient initially responded to treatment but has relapsed after HCV therapy was discontinue \ NONRESPONSE: Patient did not experience a 2 log decrease in viral load after at least 12 weeks of therapy \ PARTIAL RESPONSE: experienced virological breakthrough (e.g., experienced a 2 log decrease in viral load or undetectable viral load at week 12 but became positive later) 13. Is this the first time the patient has ever been retreated with pegylated interferon and ribavirin for HCV? 14. Is the patient prescribed ribavirin in combination with Infergen? 15. Has the patient had a nonresponse with prior HCV therapy? NONRESPONSE: Patient did not experience a 2 log decrease in viral load after at least 12 weeks of therapy \ PARTIAL RESPONSE: experienced virological breakthrough (e.g., experienced a 2 log decrease in viral load or undetectable viral load at week 12 but became positive later) 16. Is this the first time the patient has ever been retreated for HCV? 17. Is the patient using ribavirin with an alfa interferon (i.e. Pegasys, PegIntron, Infergen, or Intron-A)?

3 18. Is the patient coinfected with human immunodeficiency virus (HIV)? [If no, skip to question 20.] 19. Is the patient currently receiving or will be receiving Videx (didanosine)? [If no, skip to question 28.] 20. Is the patient Genotype 1 or Genotype 4? [If yes, skip to question 22.] 21. For Genotype 2 or 3, has the patient received greater than or equal to 24 weeks of 22. Has the patient received greater than or equal to 12 weeks of 23. Did the patient have UNDETECTABLE HCV RNA at week 12 of [If yes, skip to question 28.] 24. Did the patient have greater than or equal to 2 log decrease in viral load after 12 weeks of 25. Has the patient received greater than or equal to 24 weeks of 26. Did the patient have UNDETECTABLE HCV RNA after 24 weeks of 27. Does the patient have Genotype 1 HCV? [If yes, skip to question 29.] 28. Has the patient received greater than or equal to 48 weeks of 29. Has the patient received greater than or equal to 72 weeks of 30. Does the patient have genotype 1 infection? 31. Does the prescribed regimen also include pegylated interferon (i.e., Pegasys or PegIntron)? 32. Is the patient currently receiving or has the patient received Victrelis as part of current treatment course? [If yes, skip to question 35.] 33. Will the patient receive 4 weeks of PEG-IFN and ribavirin prior to starting Victrelis?

4 34. Will HCV RNA level be assessed at weeks 4, 8, 12, and 24 of 35. Has the patient received greater than or equal to 12 weeks of PEG-IFN and ribavirin and 8 weeks Victrelis? 36. Did the patient have HCV RNA greater than or equal to 100 IU/mL at week 12 of 37. Has the patient received greater than or equal to 24 weeks of PEG-IFN and ribavirin and greater than or equal to 20 weeks Victrelis? 38. Did the patient have UNDETECTABLE HCV RNA at week 24 of 39. Does the patient have cirrhosis? 40. Was the patient poorly IFN responsive (less than 1.0-log10 HCV- RNA decline in viral load) at week 4 of 41. Is the request for RETREATMENT of chronic HCV infection? [If no, skip to question 43.] 42. With prior therapy, did the patient have less than 2-log10 drop in HCV-RNA after 12 weeks of treatment (ie, null response)? 43. Did the patient have UNDETECTABLE HCV RNA at week 8 of 44. Does the patient have genotype 1 infection? 45. Does the prescribed regimen also include pegylated interferon (i.e., Pegasys or PegIntron)? 46. Will/have HCV RNA level be assessed at weeks 4, 12, and 24 of 47. Has the patient received greater than or equal to 4 weeks of ribavirin in combination with Incivek and PEG-IFN? 48. Did the patient have HCV RNA greater than 1,000 IU/mL at week 4 of 49. Has the patient received greater than or equal to 12 weeks of ribavirin in combination with Incivek and PEG-IFN?

5 50. Did the patient have HCV RNA greater than 1,000 IU/mL at week 12 of 51. Is the patient treatment-naïve or prior relapser to HCV therapy? [If no, skip to question 54.] 52. Does the patient have cirrhosis? [If yes, skip to question 54.] 53. Did the patient have UNDETECTABLE HCV RNA at weeks 4 AND 12 of 54. Has the patient received greater than or equal to 24 weeks of ribavirin in combination with PEG-IFN? 55. Did the patient have UNDETECTABLE HCV RNA at week 24 of Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature and Date