Washington prescribers request coverage of direct-acting antiviral treatment for hepatitis C accepted under a workers' compensation claim with this two-page prior authorization form. It asks for the regimen and duration chosen against the fibrosis score, genotype, antibody and viral load history, transmission risk factors, prior treatment, APRI and liver function scoring inputs, kidney function, transplant status and possible drug interactions.
The prescribing provider completes it, adds their specialty and signs; the dispensing pharmacy's name and contact details are entered at the top.
Download the current version from the source each time; forms change without notice.
Direct-Acting Antiviral for Hepatitis C Prior Authorization Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The form asks for AST and platelet count with the upper normal for APRI scoring; ascites, encephalopathy, albumin, total bilirubin and INR; creatinine clearance or eGFR; genotype; the initial HCV antibody; initial and current HCV RNA viral loads; and NS5A or NS3 resistance testing if done, each with dates.
Mavyret, Epclusa for decompensated cirrhosis, and Vosevi for FDA-approved indications, with a line for other regimens. Durations offered are 8 weeks, 12 weeks or other, chosen against the fibrosis score, from F0-F3 through compensated or decompensated cirrhosis.