West Virginia Medicaid Hepatitis-C Therapy Prior Authorization Form Instructions

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This form contains 77 fields organized into 27 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Cirrhosis Status
Cirrhosis No Checkbox
Check this box if the patient does not have cirrhosis.
Child-Pugh Score Number
Provide the patient's Child-Pugh score, if the patient has cirrhosis. Fill only if 'Cirrhosis Yes' is 'Yes'.
Depends on: Cirrhosis Yes
Cirrhosis Yes Checkbox
Check this box if the patient has cirrhosis.
Diagnosis Information
Diagnosis (ICD9 Code) Text
Enter the patient's diagnosis, including any relevant ICD9 Code.
Genotype Text
Provide the patient's genotype based on lab results.
Viral Load Number
Enter the patient's viral load from the lab results.
Drug Interaction Status
Yes Checkbox
Check this box if the patient is currently on, or is expected to be on, any interacting drug therapies.
No Checkbox
Check this box if the patient is not currently on, and is not expected to be on, any interacting drug therapies.
Fibrosis Level
F4 Checkbox
Check this box if the patient's fibrosis level is F4.
F3 Checkbox
Check this box if the patient's fibrosis level is F3.
F2 Checkbox
Check this box if the patient's fibrosis level is F2.
F1 Checkbox
Check this box if the patient's fibrosis level is F1.
HIV Co-infection Status
Yes Checkbox
Check this box if the patient is co-infected with HIV.
No Checkbox
Check this box if the patient is not co-infected with HIV.
IFN-Ineligible Reasons
IFN-Ineligible Checkbox
Check this box if the patient is interferon-ineligible based on one of the listed reasons below. Fill only if 'Is the patient co-infected with HIV?' is 'Yes'.
Depends on: Yes
Documented life-threatening side effects Checkbox
Check this box if the patient has documented life-threatening or potential side effects, such as a history of suicidality. Fill only if 'IFN-Ineligible' is 'Yes'.
Depends on: IFN-Ineligible
Decompensated cirrhosis Checkbox
Check this box if the patient has decompensated cirrhosis (Child-Pugh score > 6), or a Child-Pugh score ≥ 6 if HIV co-infected. Fill only if 'IFN-Ineligible' is 'Yes'.
Depends on: IFN-Ineligible
Blood dyscrasias Checkbox
Check this box if the patient has blood dyscrasias, indicated by a baseline neutrophil count <1500/μL, baseline platelets <90,000/µL, or baseline Hgb <10g/dL. Fill only if 'IFN-Ineligible' is 'Yes'.
Depends on: IFN-Ineligible
Pre-existing unstable or significant cardiac disease Checkbox
Check this box if the patient has pre-existing unstable or significant cardiac disease, such as a history of myocardial infarction or acute coronary syndrome. Fill only if 'IFN-Ineligible' is 'Yes'.
Depends on: IFN-Ineligible
Labwork Documentation Submission
Yes Checkbox
Check this box if the documentation being submitted is current, with labwork from within the past 3 months.
No Checkbox
Check this box if the documentation being submitted is NOT current, with labwork from within the past 3 months.
Liver Transplantation Status
Potential Transplant Date Date
Provide the potential date for the liver transplantation. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
No Checkbox
Check this box if the patient is not currently awaiting a liver transplantation.
Yes Checkbox
Check this box if the patient is currently awaiting a liver transplantation.
Other Pertinent Information
Other Pertinent Information Text
Provide any other pertinent information relevant to the request, attaching additional pages if necessary.
Patient Age Confirmation
Patient 18 years or older - Yes Checkbox
Check this box if the patient is 18 years of age or older.
Patient 18 years or older - No Checkbox
Check this box if the patient is not 18 years of age or older.
Patient Clinical Data
eGFR and Date Obtained Text
Please provide the estimated Glomerular Filtration Rate (eGFR) value and the date it was obtained. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Patient Current Weight Number
Please provide the patient's current weight.
Patient Consent Confirmation
Yes Checkbox
Check this box if the patient has been counseled on and agreed to comply with all the conditions stipulated on the Hepatitis-C Patient Consent Form, and a signed consent form will be submitted with the request.
No Checkbox
Check this box if the patient has not been counseled on and agreed to comply with all the conditions stipulated on the Hepatitis-C Patient Consent Form.
Patient Information
Patient Last Name Text
Please provide the patient's last name.
Patient First Name Text
Please provide the patient's first name.
Patient Middle Initial Text
Please provide the patient's middle initial.
WV Medicaid ID Text
Please provide the patient's 11-digit West Virginia Medicaid ID number.
Patient Date of Birth Date
Please provide the patient's date of birth.
Patient Pregnancy Status
Yes Checkbox
Check this box if the patient is pregnant.
No Checkbox
Check this box if the patient is not pregnant.
Patient's Treatment Status
Null Responder Checkbox
Check this box if the patient had no response to prior Hepatitis C treatment.
Prior Partial Responder Checkbox
Check this box if the patient previously had a partial response to Hepatitis C treatment.
Prior Relapse Checkbox
Check this box if the patient previously responded to Hepatitis C treatment but has since relapsed.
Treatment Naive Checkbox
Check this box if the patient has not received any prior treatment for Hepatitis C.
Pharmacy Address
Pharmacy Street Address Text
Enter the street address of the pharmacy.
Pharmacy City Text
Enter the city where the pharmacy is located.
Pharmacy State Combobox
Enter the state where the pharmacy is located.
District of Columbia Idaho nevada Oklahoma Washington Arizona Mississippi New York Ohio North Carolina Alabama Missouri Louisiana North Dakota California Illinois Wisonsin Michigan Maryland Florida Montana Kansas Alaska Oregon New Hampshire Iowa Rhode Island New Jersey Pennsylvania Connecticut Nebraska Virginia Colorado Maine West Virginia Arkansas kentucky Georgia Indiana Tennessee Utah South Dakota Hawaii Massachesetts Wyoming Minnesota Delaware New Mexico Vermont Texas South Carolina
Pharmacy Zip Code Text
Enter the zip code of the pharmacy.
Pharmacy Contact Information
Pharmacy 10-Digit NPI Text
Please enter the 10-digit National Provider Identifier (NPI) for the pharmacy.
Pharmacy Phone Number Text
Please enter the phone number for the pharmacy.
Pharmacy Fax Number Text
Please enter the fax number for the pharmacy.
Pharmacy Name
Pharmacy Name Text
Enter the full name of the pharmacy, if applicable.
Prescriber Address
Prescriber Street Address Text
Enter the street address of the prescriber.
Prescriber Zip Code Text
Enter the zip code of the prescriber's address.
Prescriber State Combobox
Enter the state of the prescriber's address.
District of Columbia Idaho nevada Oklahoma Washington Arizona Mississippi New York Ohio North Carolina Alabama Missouri Louisiana North Dakota California Illinois Wisonsin Michigan Maryland Florida Montana Kansas Alaska Oregon New Hampshire Iowa Rhode Island New Jersey Pennsylvania Connecticut Nebraska Virginia Colorado Maine West Virginia Arkansas kentucky Georgia Indiana Tennessee Utah South Dakota Hawaii Massachesetts Wyoming Minnesota Delaware New Mexico Vermont Texas South Carolina
Prescriber City Text
Enter the city of the prescriber's address.
Prescriber Attestation
Prescriber Signature Text
Enter the prescriber’s handwritten or electronic signature certifying that this request is medically necessary and documented in the medical records.
Prescriber Signature Date Date
Enter the date (MM/DD/YYYY) on which the prescriber signed the attestation.
Check here for electronic signature Checkbox
Check this box if you are providing an electronic signature for the attestation.
Prescriber Contact Information
Prescriber NPI Number Text
Please enter the prescriber's 10-digit National Provider Identifier (NPI) number.
Prescriber Phone Number Text
Please enter the prescriber's phone number.
Prescriber Fax Number Text
Please enter the prescriber's fax number.
Prescriber Name and Specialty
Prescriber Last Name Text
Enter the last name of the prescriber.
Prescriber First Name Text
Enter the first name of the prescriber.
Prescriber Middle Initial Text
Enter the middle initial of the prescriber.
Prescriber Specialty Text
Enter the medical specialty of the prescriber.
Prior Hep-C Treatments
Prior Hep-C Treatments Text
Provide a description of any prior Hepatitis C treatments the patient has received. Fill only if 'Null Responder', 'Prior Partial Responder', 'Prior Relapse' is selected, any.
Depends on: Prior Relapse, Prior Partial Responder, Null Responder
Reason for Failure
Reason for Failure Text
Provide a detailed explanation for the failure of previous treatments or why the current treatment plan is not working. Fill only if 'Null Responder', 'Prior Partial Responder', 'Prior Relapse' is selected, any.
Depends on: Prior Relapse, Prior Partial Responder, Null Responder
Renal Impairment Status
Yes Checkbox
Check this box if the patient has severe renal impairment (eGFR<30) or end stage renal disease.
No Checkbox
Check this box if the patient does not have severe renal impairment (eGFR<30) or end stage renal disease.
Requested Drug Regimen
Drug Regimen Details Text
Please provide the details of the requested drug regimen, including the drug, dose, and duration.
Ribavirin-Ineligible Reasons
Ribavirin-Ineligible Checkbox
Check this box if the patient meets any of the criteria for Ribavirin ineligibility listed below. Fill only if 'Does the patient have severe renal impairment (eGFR<30) or end stage renal disease?' is 'Yes'.
Depends on: Yes
History of severe or unstable cardiac disease Checkbox
Check this box if the patient has a history of severe or unstable cardiac disease. Fill only if 'Ribavirin-Ineligible' is 'Yes'.
Depends on: Ribavirin-Ineligible
Pregnant women and men with pregnant partners Checkbox
Check this box if the patient is a pregnant woman or a man with a pregnant partner. Fill only if 'Ribavirin-Ineligible' is 'Yes'.
Depends on: Ribavirin-Ineligible
ANC <1,500 cells/mm3 Checkbox
Check this box if the patient's Absolute Neutrophil Count (ANC) is less than 1,500 cells/mm3. Fill only if 'Ribavirin-Ineligible' is 'Yes'.
Depends on: Ribavirin-Ineligible
Baseline platelet count <70,000 cells/mm3 Checkbox
Check this box if the patient's baseline platelet count is less than 70,000 cells/mm3. Fill only if 'Ribavirin-Ineligible' is 'Yes'.
Depends on: Ribavirin-Ineligible
Hypersensitivity to ribavirin Checkbox
Check this box if the patient has a known hypersensitivity to ribavirin. Fill only if 'Ribavirin-Ineligible' is 'Yes'.
Depends on: Ribavirin-Ineligible
Diagnosis of hemoglobinopathy Checkbox
Check this box if the patient has a diagnosis of hemoglobinopathy (e.g., thalassemia major, sickle cell anemia). Fill only if 'Ribavirin-Ineligible' is 'Yes'.
Depends on: Ribavirin-Ineligible
Hb <12 gm/dl in women, or <13 gm/dl in men Checkbox
Check this box if the patient's hemoglobin (Hb) level is less than 12 gm/dl for women or less than 13 gm/dl for men. Fill only if 'Ribavirin-Ineligible' is 'Yes'.
Depends on: Ribavirin-Ineligible