New Prior Approval (PA) Forms for Hepatitis C Medications

Drug Request Forms Webpage

Prior approval for Hepatitis C medications can be requested via the secure provider portal using Drug Type: Preferred for Viekira or Drug Type: Non-Preferred for the other Hepatitis C agents. When submitting a PA request for Hepatitis C medications via the portal, the required forms and documentation must be uploaded via the attachment feature. Requesting these medications via the provider portal is the fastest and most efficient method for obtaining prior approval. Refer to the User Guides page of the provider portal for “How to Submit Prior Approval Attachments in NCTracks” under the heading Prior Approval.

When submitting a PA request for Hepatitis C medications via fax or mail, you must submit the Standard Prior Approval Request Form as the top page followed by the required new Hepatitis C form and documents indicating criteria has been met. (The Standard Prior Approval Request Form can also be found on the Drug Request Forms webpage.) The Hepatitis C form and documents should be the second and subsequent pages in the fax or mailed package. Only submit one prior approval request per fax.

Note: When requesting Daklinza for genotype 3 HCV, be sure to also send a request for Sovaldi.  Both medications are required for genotype 3 and each requires a separate prior approval.

Prior Approval for Hepatitis C medications requires that the provider submit medical records and documentation of the diagnosis of chronic Hepatitis C with genotype and subtype if applicable. Specific drug requirements and needed documentation are outlined on the Prior Approval Drugs and Criteria webpage of the NCTracks website, under the Hepatitis C medications link.

Below is a summary of the forms and documentation that must be submitted with the PA request, regardless of the method of submission:

 

NEW HEPATITIS C FORM(S)	The forms can be found on the Drug Request Forms webpage under the heading "Temporary Hepatitis C Forms,” based on the type of Hepatitis C medication requested.
DOCUMENT 1	Medical record documentation for diagnosis of chronic hepatitis C with genotype and subtype (if applicable)
DOCUMENT 2	Medical record documentation for Fibrosis stage
DOCUMENT 3	Actual lab results (not progress notes) showing HCV RNA levels. For initial requests, lab results must be collected in the previous 6 months. For continuation, lab results must be collected 4 or more weeks after the first prescription fill date.
DOCUMENT 4	Additional information such as patient’s health status and history, treatment plan, contra-indications etc. (if applicable) The patient “readiness to treat” form is required for initial PAs, regardless of submission method, and must be signed and dated by the beneficiary and attached as well.