CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization form for chronic Hepatitis C antiviral therapy (Vosevi)

This document is a prior authorization request form governing coverage determinations for beneficiaries seeking treatment for chronic Hepatitis C (all genotypes) with Vosevi; it affects prescribing providers and their prior authorization submissions to Colorado Rocky Mountain Health Plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization form for chronic Hepatitis C antiviral therapy (Vosevi)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required clinical and administrative documentation including genotype/subtype and quantitative HCV RNA within 6 months, plus prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum beneficiary age queried

1-6HCV genotypes addressed

12 wktherapy length option

6 mobaseline viral load timing

Coverage Criteria for Vosevi (Chronic Hepatitis C)

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Authorization criteria

Covered when ALL of the following are met (information collected on form):

Age: Beneficiary is 18 years of age or older>=18 years

form checkbox

Diagnosis and genotype: Diagnosis of chronic Hepatitis C with confirmed genotype 1, 2, 3, 4, 5, or 6genotype 1-6

form requests genotype and subtype

Cirrhosis status: Without cirrhosis or with compensated cirrhosis (Child-Pugh grade)compensated cirrhosis

form collects Child-Pugh grade

Prior treatment history assessment: Provider documents prior HCV treatment history (whether previously treated with an NS5A-containing regimen, or treated with sofosbuvir without an NS5A inhibitor where relevant)

form asks prior-treatment questions to guide regimen selection

Clinical documentation attached: Medical records documenting chronic hepatitis C with genotype and subtype are submitted and lab test results are attached

Lab test results MUST be attached to the PA to be approved

Baseline viral load: Documented quantitative HCV RNA at baseline tested within the past 6 monthsHCV RNA within 6 months

medical documentation required

Prescriber attestation and signature: Prescriber attests treatment will improve overall health and confirms no FDA‑labeled contraindication to Vosevi; prescriber signature and date provided

Prescriber signature mandatory

The form asks whether the beneficiary has any FDA‑labeled contraindications to Vosevi. If a contraindication is present, the request would be excluded from approval. The prescriber must indicate the presence or absence of contraindications on the form as part of the attestation process.

Incomplete requests may not be approvable. Specifically, requests missing documentation of genotype/subtype, lacking a quantitative HCV RNA tested within the past 6 months, or missing the prescriber signature (the form notes the prescriber signature is mandatory) can result in denial or requests for additional information.

Coding & Laboratory Timing

No codes provided on formmixed

No codes listed

Baseline quantitative HCV RNA timing

Required timing for baseline quantitative HCV RNADocumented quantitative HCV RNA at baseline tested within the past 6 months (medical documentation required); lab test results MUST be attached to the PA to be approved.

What to submitAttach laboratory report showing quantitative HCV RNA (IU/mL and/or log10 value) from within the prior 6 months.

Consequence of missing resultFailure to attach the required lab test results will prevent approval of the prior authorization request.

Form field capturedQuestion asks: 'Does the beneficiary have a documented quantitative HCV RNA at baseline that was tested within the past 6 months?' with Yes/No and space for HCV RNA (IU/ml) and/or log10 value.

Provider Required Actions & Documentation

Prior Authorization

Prior authorization form completion — completed form required

Prior authorization form must be completed and submitted with beneficiary and prescriber details, drug information, and therapy length indicated. The completed form is required before the PA can be processed.

Include beneficiary name, ID, DOB, and gender
Provide prescriber NPI, fax, and requester contact name/phone
Specify drug name, strength, quantity per 30 days, and length of therapy (e.g., 12 weeks)

Denial Risk

Missing required laboratory and medical documentation — attach labs/records

Attach all required laboratory and medical documentation. Lab test results and medical records documenting chronic HCV, genotype/subtype, and baseline quantitative HCV RNA (tested within the past 6 months) MUST be included with the PA or the request may be delayed or denied.

Medical records documenting diagnosis of chronic Hepatitis C with genotype and subtype
Quantitative HCV RNA at baseline (IU/ml and/or log10) performed within prior 6 months
If labs/medical records are missing, the PA may be denied or returned for more information

Documentation Required

Administrative documentation — beneficiary/prescriber details and signature required

Provide complete administrative documentation on the PA form, including beneficiary and prescriber identifiers and prescriber signature. Incomplete administrative data will delay processing.

Beneficiary last name, first name, beneficiary ID, date of birth, and gender
Prescribing provider NPI, provider fax, requester contact name and phone/extension
Prescriber signature and date (mandatory), and prescriber contact information

Background

This prior authorization form is used to request treatment with Vosevi for chronic Hepatitis C (CHC) infection across genotypes 1–6, including beneficiaries without cirrhosis or with compensated cirrhosis. The form collects clinical details—age confirmation (≥18 years), confirmed genotype and subtype, Child‑Pugh grade, prior HCV treatment history, and a baseline quantitative HCV RNA tested within the past 6 months—and includes a mandatory prescriber attestation and signature to support the coverage determination.

Definitions

Chronic Hepatitis C (CHC) — genotype and cirrhosis

Definition of CHCDocumented chronic Hepatitis C infection with confirmed genotype and subtype requiring antiviral therapy.

Genotypes queried on formForm queries confirmed genotype 1, 2, 3, 4, 5, or 6.

Cirrhosis status capturedForm specifies 'without cirrhosis or with compensated cirrhosis' and requests Child-Pugh grade.

Prior treatment history capturedForm asks whether beneficiary was previously treated with an NS5A-containing regimen or with sofosbuvir without an NS5A inhibitor (with genotype-specific follow-up), to inform regimen selection.