CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hepatitis C Prior Authorization Form

This document is a prior authorization (PA) form for Hepatitis C medications for Neighborhood Health Plan of Rhode Island members, collecting member, prescriber, prescription, and clinical assessment information and listing specialty pharmacy routing instructions and contact numbers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHepatitis C Prior Authorization Form

Policy CodePolicy N/A

Change Typeclarified (administrative)

Effective Date

Next Review Date

Key ActionProvider must complete and fax the authorization form with all applicable documentation (clinical assessments, fibrosis staging documentation, prior treatment history, rationale for non-preferred agents) to the Pharmacy Department or one of the listed specialty pharmacies.

POLICY UPDATE CHANGES

Form updated December 2022 (header shows 'Updated: December 2022').

3Listed Specialty Pharmacies

MultipleRequired Clinical Data Fields

Hepatitis C Prior Authorization Form — Purpose & Scope

This is a prior authorization (PA) form for Hepatitis C medications for Neighborhood Health Plan of Rhode Island members. It collects member identifying information (name and ID), prescription details (medication name/strength, directions, quantity, refills), prescriber information (name, specialty, address, phone, fax, office contact, NPI, signature and date), and clinical assessment information. The form lists routing instructions to the Limited Specialty Pharmacy Network and provides contact phone and fax numbers for the specialty pharmacies and the plan’s Pharmacy Department.

Key Metadata

PayerNeighborhood Health Plan of Rhode Island

Document typeadministrative

SubjectHepatitis C Prior Authorization Form

StatusCURRENT

Last review2022-12-01

Scope summaryThis document is a prior authorization (PA) form for Hepatitis C medications for Neighborhood Health Plan of Rhode Island members, collecting member, prescriber, prescription, and clinical assessment information and listing specialty pharmacy routing instructions and contact numbers.

Clinical Assessment Fields Required on PA

Clinical Assessment Fields (information to be provided with PA request)

Complete all requested information:

Clinical assessment fields

Member identifying information: Member's name and ID number.
Prescription information: Medication name/strength, directions, quantity, refills.
Prescriber information: Prescriber name, specialty, address, phone, fax, office contact name, prescriber NPI, prescriber's signature and date.
Treatment status: Indicate Treatment naive or Retreatment (prior treatment failure with another HCV agent).
Vosevi note: If request is for Vosevi, no further information is required.
Current therapy start date: If currently on therapy: provide start date.
Prior HCV drugs and dates/reasons: Provide previous Hepatitis C drug(s) and date(s), and reason (side effect, inadequate response, other).
Hepatitis C genotype: Indicate genotype (2, 3, 4, Other).
Hepatic fibrosis stage: Indicate stage 0, 1, 2, 3, or 4.
Test used to determine disease stage: Check applicable tests (APRI, Fibroscan score, Fibrotest score, Imaging study, Liver biopsy indicating METAVIR score).
Documentation must be submitted with PA request.
Cirrhosis status: Is cirrhosis present? Indicate Yes (Compensated or Decompensated) or No.
Rationale for inability to use preferred agents: Rationale why member is unable to use preferred HCV agents Mavyret and/or Vosevi; clinical documentation must be provided.
Post-treatment viral load submission agreement: Whether prescriber agrees to submit post-treatment viral load data (Yes/No).

Required Provider Actions and Routing

Prior Authorization

Submit completed PA form with documentation

Provider must complete and fax the authorization form with all applicable documentation (clinical assessments, fibrosis staging documentation, prior treatment history, rationale for non-preferred agents) to the Pharmacy Department or one of the listed specialty pharmacies.

Documentation Required

Fibrosis/cirrhosis documentation required

Documentation of disease staging (APRI, Fibroscan, Fibrotest, imaging, or biopsy showing METAVIR) must be submitted with the PA request.

Billing Rule

Limited Specialty Pharmacy Network

Prescriptions must be routed to one of the listed specialty pharmacies per the Limited Specialty Pharmacy Network requirement.

Care New England Specialty Pharmacy
CVS Specialty Pharmacy
Lifespan Specialty Pharmacy

Documentation Required

Post-treatment viral load submission (if requested)

If requested, prescriber must agree to submit post-treatment viral load data.

Form Purpose & Administrative Notes

This fillable PA form is intended to gather the clinical and administrative information needed to support approval of Hepatitis C antiviral therapy. It directs providers to submit the completed form and required documentation to the Pharmacy Department or to one of the limited specialty pharmacies listed.

The form requests documentation of prior Hepatitis C therapies (drug names, dates, and reasons such as side effects or inadequate response), Hepatitis C genotype, hepatic fibrosis stage (Stage 0–4) and the test used to determine stage (APRI, FibroScan, FibroTest, imaging, or liver biopsy with METAVIR), and cirrhosis status (No, Yes — Compensated or Decompensated). It also asks whether the prescriber agrees to submit post-treatment viral load data and for a rationale with clinical documentation if the member cannot use preferred agents (Mavyret and/or Vosevi).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHepatitis C Prior Authorization Form

Policy CodePolicy N/A

Change Typeclarified (administrative)

Effective Date

Next Review Date

On This Page

OpenPayer

Hepatitis C Prior Authorization Form

Hepatitis C Prior Authorization Form — Purpose & Scope

Clinical Assessment Fields Required on PA

Required Provider Actions and Routing

Form Purpose & Administrative Notes

Document Changes