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FLORIDA MEDICAID PRIOR AUTHORIZATION
VIEKIRA PAK® (dasabuvir + ombitasvir/paritaprevir/ritonavir)
Note: Form must be completed in full.
An incomplete form may be returned.
Recipient’s Medicaid ID #
Date of Birth (MM/DD/YYYY)
/
/
Recipient’s Full Name
Prescriber’s Full Name
Prescriber License # (ME, OS, ARNP, PA)
Prescriber Phone Number
Prescriber Fax Number
VIEKIRA PAK [dasabuvir (250 mg) + ombitasvir (12.5 mg)/
paritaprevir (75 mg)/ritonavir (50 mg)]
Initiation of therapy
4 weeks
Continuation of therapy
8 weeks
12 weeks
Directions: __________________________________________
Quantity (number of daily dose packs):
______________________________
Anticipated total treatment duration: ______ weeks
Physician must submit all supporting documentation including lab results.
1. Does recipient have a diagnosis of chronic hepatitis C (070.70, 070.4, 070.5) and/or V42.7 (liver replaced by transplant)
Yes
No
2. Is prescriber a hepatologist, gastroenterologist, infectious disease specialist or transplant physician?
Yes
No
Yes
No
4. Is the recipient treatment naïve to all parts of the dasabuvir/ombitasvir/paritaprevir regimen?
Yes
No
5. Is the recipient naïve to simeprevir, sofosbuvir, and sofosbuvir/ledipasvir?
Yes
No
6. Does the recipient have decompensated liver disease?
Yes
No
If no, is the prescribing physician in consultation with a specialist indicated above?
3. What is the recipient’s HCV genotype? (attach genotype test results)
1a
1b
Other (please specify) ______________________
7. Does the recipient have HIV/AIDS? (Must have documented diagnosis and must submit most recent CD4 count-within last 6
months)
Yes
No
8. Has the prescriber submitted supporting documentation indicating the level of hepatic fibrosis?
Liver biopsy confirming Metavir Score
Transient elastography (Fibroscan)
FibroTest score
Yes
No
APRI score
Radiological imaging consistent with cirrhosis
Physical findings or clinical evidence consistent with cirrhosis as attested by prescribing physician
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FLORIDA MEDICAID PRIOR AUTHORIZATION
VIEKIRA PAK® (dasabuvir + ombitasvir/paritaprevir/ritonavir)
Note: Form must be completed in full.
An incomplete form may be returned.
9. Has the recipient had a liver transplant? (If yes, please specify date and submit supporting documentation)
Yes
Specify transplant date: ___________________
No
10. Indicate HCV RNA level (must submit lab results):
Pre-treatment baseline: ______________log10
Treatment week
Date: __________/___________/___________
Log10
Date Measured
Week 4
Week 8
Week 12
11. Has the recipient failed a prior trial of ribavirin and peg interferon alfa therapy?
If yes, please provide the recipient’s response status to prior interferon treatment.
Yes
Null
Partial
No
Relapse
12. Please document recipient’s treatment plan for HCV:
Medication Name and Strength
Directions
Therapy Begin Date
13. Has the recipient committed to the documented planned course of treatment, inclusive of anticipated blood tests and
physician visits, during and after treatment?
Yes
No
14. If the patient is a female and will be receiving ribavirin in conjunction with Viekira Pak, is there a documented negative
pregnancy test?
Yes No
15. Has recipient abstained from illicit drugs and/or alcohol consumption for a minimum of 1 month? (must submit results of test)
Yes
No
OR
Is the recipient receiving substance or alcohol abuse counseling services (must submit supporting documentation)?
Yes
No
For Continuation of Therapy:
1. Has initial review criteria been met?
Yes
No
2. Have HCV RNA lab results been collected and indicated above in HCV RNA Level table?
Yes
No
3. Has the recipient abstained from illicit drug and/or alcohol use?
Yes
No
Yes
No
Has recipient been 100% adherent to the treatment plan (verified by claims history)?
(If no, please explain why not)______________________________________________________________________
Please note: Please ensure recipient has received Hepatitis A and B vaccinations.
REQUIRED FOR REVIEW: All copies of medical records (e.g., diagnostic evaluations and recent chart notes), a copy of the original
prescription, and the most recent copies of related labs. All documentation from prescribing physician must be submitted for review.
By signing below, the prescriber attests that all statements provided are accurate.
Prescriber Signature:_____________________________________________________
Mail or Fax Information to:
Magellan Medicaid Administration, Inc.
Prior Authorization
P.O. Box 7082
Tallahassee, FL 32314-7082
Phone: 877-553-7481
Fax: 877-614-1078
Date: ____________________________________
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