Get Colorado Medicaid Prior Authorization Request Form - Colorado

Completing the Colorado Medicaid Prior Authorization Request Form accurately is essential for obtaining treatment for Hepatitis C. This guide provides clear steps to help users navigate the online process and ensure all necessary information is included.

Follow the steps to accurately complete the form online.

1. Click 'Get Form' button to download the form and open it for editing.
2. Select the preferred drug under 'Select requested drug(s) and co-administration drugs.' You may choose 'Viekira Pak' or any of the other options as applicable.
3. Fill in the member's name, date of birth (DOB), and Medicaid ID. Ensure all fields are completed to avoid processing delays.
4. Provide baseline ALT, genotype (select 1a or 1b), Child-Pugh score, pre-treatment HCV RNA levels, gender, BMI, and CrCl ml/min. Be meticulous with lab values to comply with requirements.
5. Indicate the presence of any fibrosis by selecting 'Yes' or 'No,' and provide the necessary biopsy or imaging results to support the claim.
6. Document the drug and alcohol misuse history. Attach the required screening reports, ensuring they are dated within the last 30 days if applicable.
7. Provide details regarding prior treatments if applicable, including dates and types of treatment received.
8. Specify the member's diagnosis(es) by checking the relevant boxes, and attach supporting documentation as required.
9. Confirm whether significant drug-drug interactions have been addressed. If the member is of childbearing potential, provide details accordingly, including any necessary pregnancy tests.
10. The physician must complete their section, including name, phone number, fax, NPI, and signature. Ensure the form is signed for attestation.
11. Double-check the completed form for accuracy and completeness before saving and printing it.
12. Fax the completed form and all supporting documentation to 888-772-9696. Retain a copy for your records.

Get started on submitting your forms online to ensure timely approval.