Prescriber Fax Form
MediGold
Ribavirin (ribavirin, oral)
Copegus (ribavirin tablet)
Moderiba (ribavirin tablet)
Rebetol (ribavirin capsule and oral solution)
Ribasphere (ribavirin capsules)
(Coverage Determination)
This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-855-633-7673.
Please contact CVS/Caremark at 1-866-785-5714 with questions regarding the prior authorization
process. When conditions are met, we will authorize the coverage of Ribavirin (ribavirin, oral) (Coverage
Determination).
Drug Name (select from list of drugs shown):
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
Prescribing Physician
Physician Name:
Physician Phone:
Physician Fax:
Physician Address:
City, State, Zip:
Diagnosis:
ICD Code:
Please circle the appropriate answer for each question.
1.
Prior to initiating therapy, did the patient have a diagnosis of chronic
hepatitis C virus (HCV) infection as confirmed by presence of viral load in
the serum?
[If no, no further questions.]
Yes
No
2.
Is the request for dual therapy with pegylated interferon (PegIFN [Pegasys
or PegIntron] or non- pegylated interferon?
[If no, skip to question 4.]
Yes
No
3.
Has the patient received a total 48 weeks of treatment?
[No further questions.]
Yes
No
4.
Is ribavirin being prescribed as part of the three-drug regimen that includes
PegIFN and Sovaldi?
[If no, skip to question 12.]
Yes
No
5.
Does the patient have recurrent HCV infection post liver transplantation?
[If no, skip to question 8.]
Yes
No
6.
Does the patient have HCV genotype 1 infection?
[If no, no further questions.]
Yes
No
7.
Has the patient received a total 24 weeks of treatment?
[No further questions.]
Yes
No
8.
Is the request for retreatment due to nonresponse to prior HCV therapy
with PegIFN and ribavirin with or without a protease inhibitor?
[If yes, skip to question 11.]
Yes
No
9.
Is the patient treatment-naïve OR prior relapser to PegIFN and ribavirin
therapy?
[If no, no further questions.]
Yes
No
10. Does the patient have HCV infection with genotype 1, 3, 4, 5, or 6?
[If no, no further questions.]
Yes
No
11. Has the patient received a total 12 weeks of treatment?
[No further questions.]
Yes
No
12. Is ribavirin being prescribed as part of the two-drug regimen that includes
Sovaldi?
[If no, skip to question 29.]
Yes
No
13. Does the patient have decompensated liver disease (e.g., Child-Pugh
Class B or C)?
[If no, skip to question 15.]
Yes
No
14. Has the patient received a total 48 weeks of treatment?
[No further questions.]
Yes
No
15. Does the patient have recurrent HCV infection post liver transplantation?
[If no, skip to question 17.]
Yes
No
16. Does the patient have HCV genotype 1, 2 or 3 infection?
[If yes, skip to question 23.]
[If no, no further questions.]
Yes
No
17. Is the patient diagnosed with hepatocellular carcinoma and awaiting liver
transplantation?
[If no, skip to question 20.]
Yes
No
18. Does the patient meet the MILAN criteria below?
 Tumor size 5cm or less in diameter with single hepatocellular
carcinomas OR 3 tumor nodules or less, each 3cm or less in diameter
with multiple tumors AND
 No extrahepatic manifestations of the cancer or evidence of vascular
invasion of tumor
[If no, no further questions.]
Yes
No
19. Will ribavirin be given for ≤ 48 weeks or until liver transplantation,
whichever comes first?
[No further questions.]
Yes
No
20. Does the patient have HCV genotype 1 or 4 infection?
[If no, skip to question 22.]
Yes
No
21. Does the patient have documented intolerance OR ineligibility to receive
IFN?
Must have one or more of the following.
 Autoimmune hepatitis and other autoimmune disorders
 Hypersensitivity to PEG or any of its components
 Decompensated liver disease (eg. Child-Pugh score >6 [class B
and C])
 History of depression or clinical features consistent with
depression
 Baseline neutrophil count less than 1,500
 Baseline platelet count less than 90,000
 Baseline hemoglobin less than 10 g/dL
 History of pre-existing cardiac disease
[If yes, skip to question 23.]
[If no, no further questions.]
Yes
No
22. Does the patient have HCV genotype 3 infection?
[If no, skip to question 24.]
Yes
No
23. Has the patient received a total 24 weeks of treatment?
[No further questions.]
Yes
No
24. Does the patient have HCV genotype 2 infection?
[If no, no further questions.]
Yes
No
25. Is the request for retreatment due to nonresponse to prior HCV therapy
with PegIFN and ribavirin with or without a protease inhibitor?
[If no, skip to question 27.]
Yes
No
26. Does the patient have cirrhosis?
[If yes, skip to question 28.]
Yes
No
27. Has the patient received a total 12 weeks of ribavirin therapy?
[No further questions.]
Yes
No
28. Has the patient received a total 16 weeks of treatment?
[No further questions.]
Yes
No
29. Is ribavirin being prescribed as part of the three-drug regimen that includes
Olysio and PegIFN?
[If no, skip to question 37.]
Yes
No
30. Does the patient have HCV genotype 1 infection?
[If no, skip to question 33.]
Yes
No
31. Is the patient treatment-naïve OR prior relapser to PegIFN and ribavirin
therapy?
[If yes, skip to question 35.]
Yes
No
32. Is the patient a nonresponder to prior PegIFN and ribavirin therapy?
[If yes, skip to question 36.]
[If no, no further questions.]
Yes
No
33. Does the patient have HCV Genotype 4 infection?
[If no, no further questions.]
Yes
No
34. Is the patient treatment naïve OR prior relapser to PegIFN and ribavirin
therapy?
[If yes, skip to question 36.]
[If no, no further questions.]
Yes
No
35. Has the patient received a total 24 weeks of treatment?
[No further questions.]
Yes
No
36. Has the patient received a total 48 weeks of treatment?
[No further questions.]
Yes
No
37. Is ribavirin being prescribed as part of the three-drug regimen that includes
Sovaldi and Olysio?
[If no, skip to question 45.]
Yes
No
38. Does the patient have HCV genotype 1 infection?
[If no, no further questions.]
Yes
No
39. Does the patient have recurrent HCV infection post liver transplantation?
[If no, skip to question 41.]
Yes
No
40. Has the patient received equal to or greater than 24 weeks of treatment?
[No further questions.]
Yes
No
41. Is the patient treatment-naïve OR prior relapser to PegIFN and ribavirin
therapy?
[If yes, skip to question 43.]
Yes
No
42. Is the request for retreatment due to nonresponse to prior HCV therapy
with PegIFN and ribavirin?
[If yes, skip to question 44.]
[If no, no further questions.]
Yes
No
43. Does the patient have documented ineligibility to receive interferon as
evidenced by any of the following?
 Intolerance to interferon
 Autoimmune hepatitis and other autoimmune disorders
 Hypersensitivity to PEG or any of its components
 Decompensated liver disease (e.g., Child-Pugh score ≥ 7 [class B
and C])
 History of depression or clinical features consistent with
depression
 Baseline neutrophil count less than 1,500/µL
 Baseline platelet count less than 90,000/µL
 Baseline hemoglobin less than 10 g/dL
 History of pre-existing cardiac disease
[If no, no further questions.]
Yes
No
44. Has the patient received a total 12 weeks of treatment?
[No further questions.]
Yes
No
45. Is ribavirin being prescribed as part of the three-drug regimen that includes
PegIFN and Victrelis?
[If yes, skip to question 47.]
Yes
No
46. Is ribavirin being prescribed as part of the three-drug regimen that includes
PegIFN and Incivek?
[If no, no further questions.]
Yes
No
47. Does the patient have HCV genotype 1 infection?
[If no, no further questions.]
Yes
No
48. Has the patient received a total 48 weeks of treatment?
Yes
No
Comments:
I affirm that the information given on this form is true and accurate as of this date.
Prescriber (Or Authorized) Signature and Date