Attn: Pharmacy Services
P.O. Box 30196
Salt Lake City, UT 84130-0196
801-442-9988 or 855-442-9988
Fax: 801-442-3006
MEDICARE PRIOR AUTHORIZATION FORM
VictrelisTM and IncivekTM
(boceprevir) and (telaprevir)
Therapeutic use: Treatment of chronic Hepatitis C genotype 1
Quantity Limit: Victrelis: 360 capsules per month
Incivek: 180 capsules per month
Authorization Period:
 Incivek: treatment for a total of 12 weeks
 Victrelis: treatment initially approved for 24 weeks, extension will depend on virologic response.
Patient’s Name: _____________________________________________________ DOB: ___ ___ / ___ ___ / ___ ___ ___ ___
Patient’s ID: ___ ___ ___ ___ ___ ___ ___ ___ ___
Patient’s Phone #: ( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
Diagnosis Code(s) / ICD-9 Code(s): ___ ___ ___ ___ ___; ___ ___ ___ ___ ___; ___ ___ ___ ___ ___; ___ ___ ___ ___ ___
Physician’s name: ________________________________________________________________________________________
Phone #:
( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
Fax #:
( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___
Address: ________________________________________________________________________________________________
Physician’s Signature: ________________________________________________ Date: ___ ___ / ___ ___ / ___ ___ ___ ___
Supervising Physician: ____________________________________________________________________________________
(Only required if requesting provider bills under a different provider)
Urgent Request (24 hours)
1.
2.
3.
4.
5.
6.
7.
8.
Standard Request (72 hours)
Please check “Yes” or “No” and respond to the following requests:
Which protease inhibitor is being requested?
Victrelis
Incivek
Is the prescribing physician a gastroenterologist or an infectious disease
Yes
No
physician (or has a GI specialist been consulted)?
Is the patient diagnosed with chronic hepatitis C virus (HCV)?
Yes
No
What is the HCV genotype?
1
2
3
4
5
6
Has the patient been treated previously with pegylated interferon-alfa? If yes,
Yes
No
please check one: Partial responder
Relapser
Null responder
Has the patient been treated previously with a protease inhibitor?
Yes
No
Has the patient had a liver biopsy showing bridging fibrosis or cirrhosis?
Yes
No
What is the HCV RNA viral load at baseline? _________________ Date: _______________
What is the HCV RNA viral load at T4W? ____________________ Date: _______________
What is the HCV RNA viral load at T8W? ____________________ Date: _______________
What is the HCV RNA viral load at T12W? ___________________ Date: _______________
What is the HCV RNA viral load at T24W? ___________________ Date: _______________
This form is intended for SelectHealth Advantage members only. All requests for prior authorization should be sent via fax to
1-801-442-3006. Missing, inaccurate, or incomplete information may cause a delay or denial of authorization.
Last Updated: 01/01/2013
© 2013 SelectHealth. All rights reserved. #### ##/##
Drug name
Brand name: Victrels; generic name: boceprevir
Brand name: Incivek; generic name: telaprevir
Unique Handling
Pharmacist review required for approval and denial.
AWD Research Notes
Medication: Victrelis or Incivek
Eligible:
Primary Policy:
Formulary:
Group Exceptions:
PEC:
Duplicate:
PHS History: No research required
Genotype (#4):
HCV RNA (#9):
Reauth: If Yes, initially reported HCV RNA _________ and Genotype ___________
Diagnosis:
Review Outcome:
Letter:
Note: Pharmacist review required for approval and denial.
AWD Outcome Note
(Note: All denials must be forwarded to a pharmacist for review)
Approved or Denied
Participating/Non-Participating
PA Number:
Date Range:
Spoke w/Faxed:
Letter
Cost Avoidance
Grounds for denial
Criteria for approval
Note: Pharmacist review
required for approval and denial.
Does not meet criteria for approval listed below
Hepatitis C:
Genotype 1
 Treatment meets criteria if YES to #2 and #3 AND #4 type 1 is
checked AND AND NO to #5.
 Incivek can be approved for a total of 12 weeks
 Victrelis can be initially approved for 24 weeks and may be extended
to 32 or 44 weeks of therapy (total) depending clinical scenario and
virologic response.
 For specific regimens please refer to the tables below.
 Discontinuation based on futility includes: Detectable HCV-RNA at
treatment week 24, HCV-RNA ≥ 100 IU/mL at treatment week 12
(Victrelis), HCV-RNA ≥ 1000 IU/mL at treatment week 4 or 12
(Incivek)
INCIVEK
Treatment-naïve and prior relapse patients
(NO to #5 or YES to #5 and relapse checked)
HCV-RNA
Incivek
Pegylated
Interferon
Undetectable at
weeks 4 & 12
Detectable at
weeks 4 and/or 12
Total
Treatment
Weeks 1-12
Weeks 1-24
24 weeks
Weeks 1-12
Weeks 1-48
48 weeks
Last Updated: 01/01/2013
© 2013 SelectHealth. All rights reserved. #### ##/##
Prior partial, null responder, and cirrhotic patients (YES to #5 and
partial responder or null responder OR YES to #7)
All Patients
Weeks 1-12 Weeks 1-48
48 weeks
VICTRELIS
Treatment-naïve patients (NO to #5)
HCV-RNA
Victrelis
Pegylated
Interferon
Undetectable at
Weeks 4-28
Weeks 1-28
weeks 8 & 24
Detectable at
Weeks 4-36
Weeks 1-48
weeks 8 and/or 24
Prior partial responder and relapse patients
(YES to #5 and partial responder or relapse checked)
Undetectable at
Weeks 4-36
Weeks 1-36
weeks 8 & 24
Detectable at
Weeks 4-36
Weeks 1-48;
weeks 8 and/or 24
Cirrhotic patients (YES to #7)
All patients
Week 4-48
1-48
Total
Treatment
28 weeks
48 weeks
36 weeks
48 weeks
48
Genotype 2, 3, 4, 5, or 6 marked - DENIED
Chart notes required in addition
to PA form?
Physician prescribing
requirements
Step therapy required?
Benefit coverage (medical/Rx)
Quantity limit
Approval- Facets Entry
(Pegasys and Peg Intron only)
*2 log 10 drop e.g., original HCV RNA = 476,000. New score must be below
4,760 (move 2 digits over).
Varies
Physician is a gastroenterologist or an infectious disease physician (or is
working in conjunction with one of these physicians) (see #1 on form)
No
RX
Victrelis 360 capsules per month
Service Provider = PHARMACY/OTHER (103006669101) or
HOMECARE/PATIENT’S HOME (103001926101)
Code:
Hep C for Genotype 1, 4, 5 ,6 Initial approval for 24 weeks (6 kits), 28 weeks (7 kits)
for Genotype 1 in combination with Victrelis.

1st preauthorization extension is for weeks 25-48 or 25-72.
Hep C for Genotype 2 and 3- Approved for 24 weeks maximum
Approval- PHS Entry
(On Select- Approval only needs to
be entered in PHS for Victrelis and
Incivek)
Denial- PHS Entry
(on Select- Denial only needs to be
entered in PHS for Victrelis and
Incivek)
AuthTab
Error Category Override Flags
Drug
Max Cost
Limitations Tab
Max Days = 30
Number of Fills = 3 (Incevik); 6 (Victrelis)
Notes Tab
Initials, date, drug, approved, approval period (if specified)
Note: If applicable, enter into PHS for adjudication under T4 benefit
Authorization Tab
Auth Type D Denied
Notes Tab:
Initials, date, drug, denied
Criteria not met
Denial- Facets Entry
Description: Pegasys or Peg-Intron Denied
Last Updated: 01/01/2013
© 2013 SelectHealth. All rights reserved. #### ##/##
Code: See above
Criteria not met
Description: Incivek and Victrelis Denied
From Date = Prime Date
To Date = the Date you are entering it in Facets
Service provider = pharmacy 103006669101
Code J8499
Criteria not met
RxCore- PHS Approval (T4)
AuthTab
Error Category Override Flags
Drug flag
Max Cost Flag
Limitations Tab
Days 30
Notes Tab
Initials, date, drug, approved
Approval period (if specified)
Authorization Tab
Auth Type D Denied
Notes Tab:
Initials, date, drug, denied
RxCore- PHS Denial (T4)
Letter Text
Authorization Tab
Auth Type D Denied
Notes Tab:
This medication has been approved as a medical benefit for __ kits.
Per SelectHealth Pharmacy criteria and the American Gastroenterological
Association (AGA) guidelines, the patient has already used the recommended length
of treatment which is ___ weeks of therapy. Therefore, the request for Peg-Intron has
been denied.
Per SelectHealth Pharmacy criteria, the requested medication Pegasys has been
denied.
HCV RNA does not indicate an active infection.
Per SelectHealth Pharmacy criteria, the patient must have documented response to
treatment, specifically a significant drop in their viral load, to be approved for
continuation of therapy. The chart notes submitted show an increase in their viral
load, therefore the request for continuation of therapy has been denied.
Per SelectHealth Pharmacy criteria, the requested medication Peg-Intron has been
denied. Extending treatment to 72 weeks does not result in an overall improvement in
Sustained Viral Response.
Cost Avoidance
Important drug distribution
information
HPI reviewers
References
Per SelectHealth Pharmacy criteria, the requested medication Pegasys has been
denied. Retreatment is not recommended for non-Genotype 1 previous failed
treatment with peginterferon and ribavirin.
$15,532 Pegasys- 24 weeks $20,160 Peg-Intron- 12 weeks
Incivek: $49,200 for 12 weeks of therapy
Victrelis: $26,400 for 24 weeks of therapy
Members can enroll in Be In Charge program (Schering; 1-888-HEP-2608) or
PegAssist program (Roche; 1-877 734-2797 or www.pegasys.com).
 Department pharmacist.
 Ghany MC, Strade DB, Thomas DL, Seeff LB. American Association of
the Study of Liver Diseases (AASLD) Practice Guidelines: Diagnosis,
Management, and Treatment of Hepatitis C: An Update. Hepatology
2009; vol 49(4): 1335-1374.
 Strader DB, Wright T, Thomas DL et al. American Association of the
Study of Liver Diseases (AASLD) Practice Guidelines: Chronic Hepatitis
C. Hepatology 2004;vol 39 (4):1147-1170.
Last Updated: 01/01/2013
© 2013 SelectHealth. All rights reserved. #### ##/##

Disease state
Background drug information
Authorization period
Chopra S, Bisceglie AM. Pegylated interferon in the treatment of chronic
hepatitis C virus infection. UpToDate: www.uptodate.com (accessed
6/22/2007).
 Lok AS, McMahon BJ. American Association of the Study of Liver
Diseases (AASLD) Practice Guidelines: Chronic Hepatitis B. Hepatology
2007;vol 45 (2):508-539.
 Lok AS. Standard and pegylated interferon for chronic hepatitis B virus
infection. UpToDate: www.uptodate.com (accessed 6/22/2007).
Hepatitis C virus (HCV):
 A diagnosis of chronic HCV is made based on the presence of HCV
RNA, elevated ALT, and inflammation on liver biopsy
 There are 6 different HCV genotypes (1,2,3,4,5,6), with genotype 1
being the most common and most difficult to treat
Definitions:
 Rapid virological response (RVR): HCV RNA negative at treatment
week 4
 Early virological response (EVR): >2 log 10 reduction in HCV RNA
compared to baseline at treatment week 12
 Sustained virological response: HCV RNA negative 24 weeks after
cessation of treatment
Hepatitis C:
 PEG-Intron (PEG interferon alpha-2b) or Pegasys (PEG interferon alpha2a), in combination with the oral antiviral Ribavirin, is currently the
treatment of choice for chronic HCV
 Dosing:
 PEG-Intron: 1.5 µg/kg injected subcutaneously once weekly (in
combination with Rebetol™)
 Ribavirin (Rebetol) in combination with Peg-Intron:
 <75kg: 1000 mg/day in 2 divided doses
 >75kg: 1200 mg/day in 2 divided doses
 Pegasys: 180 µg (1.0 mL) injected subcutaneously once weekly
 Ribavirin (Copegus™) in combination with Pegasys:
 Genotype 1,4; <75kg: 1000 mg/day in 2 divided doses
 Genotype 1,4; >75kg: 1200 mg/day in 2 divided doses
 Genotype 2,3: 800 mg/day in 2 divided doses
 Protease Inhibitors are indicated in the treatment of HCV Genotype 1
infection in combination with peginterferon alfa and ribavirin in adult
patients with compensated liver disease, including cirrhosis, who are
previously untreated or who have failed previous interferon and ribavirin
therapy, including prior null responders, partial responders, and
relapsers
 Dosing:
 Victrelis: 800 mg (four 200-mg capsules) three times daily (every 7-9
hours) with food
 Incivek: 750 mg (two 375-mg capsules) three times daily (every 7-9
hours) with food
Hepatitis C:
 Initial treatment: Duration of therapy is dependent on viral genotype
and achievement of a virologic response :
 Genotypes 1 refer to duration of therapy tables above
 Genotype 4,5,6 treated for 48 weeks if EVR , 72 weeks if viral
clearance between 12 and 24 weeks
 Genotype 2 and 3 for 24 weeks
This form is intended for SelectHealth members only. All requests for preauthorization should be sent via fax to 1-801-442-3006.
Missing, inaccurate, or incomplete information may cause a delay or denial of authorization.
Preauthorization Internal Documentation
Last Updated: 01/01/2013
© 2013 SelectHealth. All rights reserved. #### ##/##