Prior Authorization. Drug Name (select from list of drugs shown) Viekira Pak (ombitasv-paritaprev-ritonav-dasabuv) Quantity Frequency Strength

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1 06/01/2016 Prior Authorization Aetna Better Health Texas Viekara Pak w or w/o Ribavirin First Fill (Med) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health Texas (Bexar and Tarrant) at When conditions are met, we will authorize the coverage of Viekara Pak w or w/o Ribavirin First Fill (Med). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (select from list of drugs shown) Viekira Pak (ombitasv-paritaprev-ritonav-dasabuv) Quantity Frequency Strength Route of Administration Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Expected Length of therapy Other, Please specify Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. 1. Is the requested regimen Viekira Pak with or without ribavirin? [If no, no further questions. Please choose the form that corresponds to the requested regimen.] 2. Has the patient been previously approved for hepatitis C therapy by Texas Medicaid? [If yes, stop review and open Viekira Pak HCV TX Medicaid Refill PA ]

2 3. Is the patient currently on treatment and is transitioning to Texas Medicaid? (ote: Currently on treatment meaning the patient is currently taking medication to treat HCV supplied by a plan other than Texas Medicaid.) [If yes, stop review and open Viekira Pak HCV TX Medicaid Refill PA ] 4. Has the patient previously failed to complete treatment with a direct acting HCV agent (e.g., Sovaldi, Harvoni, Olysio, or Viekira Pak)? [If no, skip to question number 7.] 5. Was this failure due to lack of adherence? 6. Was this failure due to a health care plan denial? 7. Is the patient at least 18 years of age? 8. Does the patient have end stage renal disease (i.e., CrCl less than 30 ml/min)? 9. Has the Texas Medicaid/CHIP Vendor Drug Program Patient Education for Hepatitis C Treatment Prescriber Certification form been submitted signed by both the physician and the patient?

3 10. Has the prescriber confirmed that the patient is mentally competent, able to make appropriate decisions about treatment, and capable of completing therapy? 11. Does the patient have a negative drug test confirmed at least 30 days prior to starting treatment? Drug test to include both legal and illegal drugs which are not verifiable by prescription. 12. Does the patient have a history of substance use disorder? [If no, skip to question number 14.] 13. Has the patient initiated a substance use disorder treatment program at least 6 months prior to the start of treatment? 14. Is the patient consuming alcohol? 15. Is the patient s METAVIR score F0, F1, or F2? [If no, skip to question number 17.] 16. Does the patient have hepatocellular carcinoma or previous liver transplant? [If yes, skip to question number 18.] 17. Is the patient s METAVIR score F3 or F4?

4 18. If applicable, has the patient or the patient s female partner confirmed that they are not pregnant or attempting conception? (Confirmation via pregnancy test completed within the last 30 days is required for the patient only. If not applicable, answer 19. Are the medications prescribed by, or in conjunction with, a board certified gastroenterologist, hepatologist, or infectious disease specialist? (Collect MDs name.) 20. Has the physician submitted laboratory results for ALL of the following tests that were drawn within the last 30 days? AST (aspartate aminotransferase) \ SCr (serum creatinine) \ CrCl (creatinine clearance) \ Hgb (hemoglobin) \ WBC (white blood cells) \ AC (absolute neutrophil count) \ Plt (platelets) [If no, no further questions. Please submit laboratory results to proceed.] 21. Are all of the tests in compliance with their respective critical values? 22. Has the physician submitted laboratory results for ALL of the following tests? Baseline HCV RA level: Must be drawn within the last 30 days \ METAVIR score: Documentation of tests used to calculate METAVIR score must also be submitted. Either a liver biopsy within the last 5 years or two non-invasive tests (e.g., ActiTest, FIB4, Fibroscan, FibroSURE) from the last two years. [If no, no further questions. Please submit laboratory results to proceed.]

5 23. Is the virus genotype 1a, 1b, or 4? [If no, skip to question number 25.] 24. Does the patient have decompensated cirrhosis? [o further questions] 25. Is the virus genotype 2 or 3? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date