United Healthcare - Urgent - 24 Hour - Specialty Medication Prior Authorization Cover Sheet Page 3
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1
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3Hepatitis C Medication
PRIORAUTHORIZATION REQUEST FORM
Page 2 of 2
Has this patient been treated for Hepatitis C previously? □ YES □ NO
If yes, must provide details of previous therapy including names of medications used, dates of
therapy, and outcome of treatment / reason for discontinuing:
Trial
Regimen (List all
Dates of
Treatment
Outcome of Treatment or
medications tried with
Therapy
Completed
Reason for Discontinuation
each trial)
Yes or No
1
2
Has drug / alcohol abuse been discussed with this patient? □ YES □ NO
Has a drug screen been completed in the last 90 days? □ YES □ NO **MUST SUBMIT RESULTS**
**Must provide documentation to confirm baseline negative drug screen results within the last 90 day
Does the patient have decompensated liver disease defined as a Child-Pugh class B or C? (Must
submit supporting labs and chart documentation) □ YES □ NO
What is this patient’s Child-Pugh Class? _________________________________________________
Does the patient have hepatocellular carcinoma? □ YES □ NO
If yes, is this patient awaiting a liver transplant? □ YES □ NO
***THIS SECTION MUST BE COMPLETED FOR PATIENTS WITH GENOTYPE 1***
Are you requesting an interferon free regimen for this patient? □ YES □ NO
If yes, what is the clinical rationale for requesting an interferon free regimen? (Must include chart
documentation to support response) _____________________________________________________
_____________________________________________________________________________________
Does this patient have evidence of stage 3 or stage 4 hepatic fibrosis that includes one of the
following? (Must submit supporting labs and chart documentation) □ YES □ NO
• Liver biopsy confirming a METAVIR score of F3 or F4 or an alternative scoring equivalent
• Transient elastography (Fibroscan) score greater than or equal to 9.5kPa
• FibroTest (FibroSURE) score of greater than or equal to 0.58
• APRI score greater than 1.5
• Radiological imaging consistent with cirrhosis
• Physical findings or clinical evidence consistent with cirrhosis documented in the patient’s
chart
Does the patient have NS3 Q80K polymorphism? □ YES □ NO If yes, must submit supporting labs
Does the patient have IL28B-CC genotype status? □ YES □ NO If yes, submit supporting labs
**ALL supporting labs and chart documentation is required for medical review of this request**
Physician Signature:______________________________________________ Date: _____________
Confidentiality Notice: This transmission contains confidential information belonging to the sender and UnitedHealthcare. This information
is intended only for the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying,
distribution or action involving the contents of this document is prohibited. If you have received this telecopy in error, please notify the
sender immediately.
Phone: 800-310-6826
Fax: 866-940-7328
Website:
UHC-HepC- Updated 3.27.14
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