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  • Hepatitis C Treatment Medication Precertification Request Form

Get Hepatitis C Treatment Medication Precertification Request Form

Patient DOB G. CLINICAL INFORMATION Section 1 - Required clinical information must be completed in its entirety for all precertification requests. Circle current treatment week: 20 22 What is the viral genotype? Check one - Hepatitis C genotype: 0 2 4 6 8 10 12 14 16 18 1 24 2 26 28 3 30 4 32 34 36 38 40 42 44 46 48 Other (specify): No Has the patient had any prior therapy with a pegylated ? (other than the current requested treatment regimen) Yes If y.

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Treatment is recommended for all patients with acute or chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV therapy, liver transplantation, or another directed therapy.

Many insurance providers still have restrictions in place, preventing many people with hepatitis C from accessing lifesaving treatments. These include: The patient must have liver damage (called “fibrosis”). The doctor who writes the prescription must be a liver disease or infectious disease specialist.

Approve for 16 weeks if the individual meets the following criteria (A, B, C, and D): A) Individual is ≥ 3 years of age; AND B) Individual does not have cirrhosis or has compensated cirrhosis (Child-Pugh A); AND C) Individual had a prior null response, prior partial response, or had relapse after prior treatment with ...

The newest drugs for the treatment of hepatitis C include Mavyret (glecaprevir and pibrentasvir), Vosevi (, velpatasvir, and voxilaprevir), and Epclusa ( and velpatasvir).

LabCorp offers test 140659 – Hepatitis C Virus (HCV) Antibody to assess exposure to hepatitis C virus infection. All positive results reports will include a message that CDC guidelines recommend follow-up utilizing an approved NAT confirmation test.

Yes. However, less than half of people who are infected with the hepatitis C virus clear it from their bodies without treatment. Experts do not fully understand why this happens for some people.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232