I Affirm That the Information Given on This Form Is True and Accurate As of This Date

10/22/2015 <%PANumber%> Prior Authorization

AETNA BETTER HEALTH OF TEXAS MEDICAID (BEXAR) Sovaldi-Ribavirin w or w/o PegINF Refill (Med) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health of Texas Medicaid (Bexar) at 1- 844-275-1084. Please contact Aetna Better Health of Texas Medicaid (Bexar) at 1-800-248-7767 with questions regarding the Prior Authorization process. When conditions are met, we will authorize the coverage of Sovaldi-Ribavirin w or w/o PegINF Refill (Med).

Drug Name (select from list of drugs shown) Ribavirin Sovaldi (sofosbuvir)

Quantity Frequency Strength Route of Administration Expected Length of Therapy

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:

Comments:

Please circle the appropriate answer for each question. 1. Is the requested regimen Sovaldi and ribavirin with or Y N without pegylated interferon? [If no, no further questions. Please choose the form that corresponds to the requested regimen.] 2. Has the patient been previously approved for hepatitis C Y N therapy by Texas Medicaid? [If yes, skip to question number 4.] 3. Is the patient transitioning into Texas Medicaid while Y N currently on treatment? [If yes, no further questions.] [If yes, no further questions.] 4. Is the patient compliant with their medication, defined as Y N refills picked-up within 7 days of the exhaustion of the previous supply? [If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 5. Has the patient continued to abstain from drugs and Y N alcohol? [If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 6. Is this request to cover weeks 6 to 12 of treatment? Y N

[If no, skip to question number 16.] 7. Have updated week four laboratory results been submitted Y N on the Texas Medicaid Refill Request Form? [If no, no further questions. Please submit laboratory results to proceed.] 8. Are all tests in compliance with their respective critical Y N values? [If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 9. Were the week 4 HCV RNA levels submitted? Y N

[If no, no further questions. Please submit laboratory results to proceed.] 10. Is the virus genotype 2 or 3? Y N

[If yes, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 11. Is the virus genotype 4? Y N

[If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 12. Does the patient have decompensated cirrhosis? Y N

[If yes, skip to question number 15.] 13. Does the patient have an allergy to one of the medications Y N in Viekira Pak? [If yes, skip to question number 15.] 14. Does the patient have a severe drug interaction with Viekira Y N Pak? [If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 15. Does the patient meet ANY of the following criteria? Y N

Documentation of severe hypersensitivity to interferon or any of its components \ Autoimmune hepatitis and other autoimmune disorders \ Baseline neutrophil count below 1500 per mcL \ Baseline platelet count below 90,000 per mcL \ Baseline hemoglobin below 10 grams per dL in patients without cardiac disease \ Baseline hemoglobin below 12 grams per dL in patients with cardiac disease \ Creatinine clearance below 30 mL per minute \ Patient is on hemodialysis \ History of preexisting severe or uncontrolled cardiac disease \ Major uncontrolled depressive illness [No further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 16. Is this request to cover weeks 13 to 18 of treatment? Y N

[If yes, skip to question number 23.] 17. Is this requests to cover weeks 19 to 24 of treatment? Y N [If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 18. Have updated week twelve laboratory results been Y N submitted on the Texas Medicaid Refill Request Form? [If no, no further questions. Please submit laboratory results to proceed.] 19. Are all tests in compliance with their respective critical Y N values? [If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 20. Were the week 12 HCV RNA levels submitted? Y N

[If no, no further questions. Please submit laboratory results to proceed.] 21. Does the week 12 HCV RNA level show a significant Y N decrease from baseline? [If yes, skip to question number 23.] 22. Is the lack of a decrease in the HCV RNA due to non- Y N compliance? [If yes, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 23. Is the virus genotype 3? Y N

[If yes, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 24. Is the virus genotype 4? Y N

[If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 25. Does the patient have decompensated cirrhosis? Y N

[If yes, skip to question number 28.] 26. Does the patient have an allergy to one of the medications Y N in Viekira Pak? [If yes, skip to question number 28.] 27. Does the patient have a severe drug interaction with Viekira Y N Pak? [If no, no further questions. Please see Texas Medicaid Prior Authorization Criteria and Policy.] 28. Does the patient meet ANY of the following criteria? Y N

Documentation of severe hypersensitivity to interferon or any of its components \ Autoimmune hepatitis and other autoimmune disorders \ Baseline neutrophil count below 1500 per mcL \ Baseline platelet count below 90,000 per mcL \ Baseline hemoglobin below 10 grams per dL in patients without cardiac disease \ Baseline hemoglobin below 12 grams per dL in patients with cardiac disease \ Creatinine clearance below 30 mL per minute \ Patient is on hemodialysis \ History of preexisting severe or uncontrolled cardiac disease \ Major uncontrolled depressive illness

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (Or Authorized) Signature and Date