Get Ks Hepatitis C Agents Prior Authorization Form 2020-2025

This guide provides a comprehensive overview of the KS Hepatitis C Agents Prior Authorization Form. It offers step-by-step instructions to assist users in completing the form effectively and accurately online.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to obtain the complete form and open it in an online editor.
2. Complete the Member Information section, including the member's name, Medicaid ID, date of birth, and gender.
3. Fill out the Prescriber Information section with the prescriber’s name, Medicaid ID, National Provider Identifier (NPI), phone number, address, city, state, zip code, and fax.
4. In Section I, select the specific medication(s) requested by checking the appropriate box next to the medication name. Provide the NDC/HCPCS code, strength, dosage form, quantity, directions for use, indication/diagnosis, and ICD-10 code. Include the patient’s weight and expected duration of treatment.
5. If the requested medication is a non-preferred medication, complete Section II by indicating yes or no and providing documentation of clinical rationale if applicable.
6. In Section III, provide detailed clinical information for all requests, including the patient’s genotype, Child-Pugh class, organ transplant information, treatment history, and current HCV RNA level.
7. For treatment-experienced patients, complete Section IV by documenting the prescribing physician’s specialty, details regarding previous treatment outcomes, and any consults.
8. Review the information for accuracy, sign, and date the form prior to submission.
9. Once completed, users can save changes, download, print, or share the form as required.

Start completing your KS Hepatitis C Agents Prior Authorization Form online now to ensure a smooth processing experience.