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This document is a Prior Approval Form for Peg-Intron, used by Blue Cross Blue Shield of Vermont and The Vermont Health Plan to request approval for treatment of patients diagnosed with Chronic Hepatitis
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How to fill out bcbsvttvhp peg-intron pa form
How to fill out BCBSVT/TVHP Peg-Intron PA Form
01
Obtain the BCBSVT/TVHP Peg-Intron PA Form from the official website or request a copy from your provider.
02
Fill out the patient's information at the top of the form, including name, date of birth, and insurance details.
03
Provide details about the medical diagnosis, including ICD-10 codes if applicable.
04
Specify the prescribed treatment plan, dosage, and frequency of Peg-Intron administration.
05
Include the physician's information, including name, contact number, and NPI number.
06
Attach any necessary medical records or supporting documentation, such as previous treatment history.
07
Review the form for completeness and accuracy before submitting.
08
Submit the form via the specified method (fax, mail, or online) as indicated on the form.
Who needs BCBSVT/TVHP Peg-Intron PA Form?
01
Patients who have health insurance coverage through BCBSVT or TVHP and are prescribed Peg-Intron for treatment conditions such as Hepatitis C.
02
Healthcare providers seeking prior authorization for Peg-Intron on behalf of their patients.
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People Also Ask about
Is peg better than ?
Peginterferon has fewer side effects and better antiviral efficacy. Furthermore, viral clearance occurs more rapidly than the standard therapy in most responders. In patients without end-stage renal disease, pegIFN has a sustained response rate of 39%, more than double the rate of standard IFN.
What is peg for hepatitis B?
Treatment with PEG-IFN-α2a or PEG-IFN-α2b for 1 year resulted in HBeAg seroconversion in 22–27% at the end of treatment and 29–32% at 6 months post treatment. Off-treatment viral suppression (defined as HBV DNA <400 copies/mL) was achieved in 7–14%, and HBsAg seroconversion occurred in 3–5% of patients (16,17).
What are the advantages of PEG IFN?
PEG-IFN treatment has the benefit of finite treatment duration, a higher rate of HBeAg and HBsAg seroconversion, a higher chance of sustained off-treatment response, and no drug resistance (13).
What is a peg INF injection used for?
Peginterferon alpha-2a injections treat chronic hepatitis C and B infections. They work by reducing the amount of the virus in your body. They don't cure hep C and B and don't prevent you from spreading the virus to other people.
What is the use of peg ?
Peginterferon alfa-2a injection is used alone or together with other medicines (eg, ribavirin)to treat chronic hepatitis C infection in patients who are not able to take other medicine. It is also used to treat chronic hepatitis B infection.
What is peginterferon alfa-2b used for?
Peginterferon alfa-2b injection is used in people with malignant melanoma (a life-threatening cancer that begins in certain skin cells) who have had surgery to remove the cancer. This medication is used to reduce the chance that malignant melanoma will come back and must be started within 84 days of the surgery.
How is pegylated administered?
Pegylated alfa-2a is administered as a subcutaneous injection, typically in the thigh or abdomen. It is available as a sterile, preservative-free solution in single-use vials or prefilled syringes. The standard adult dose is 180 mcg injected once weekly.
Is peg chemotherapy?
Peginterferon alfa-2a (Pegasys®) is an Immunotherapy Regimen for Polycythemia Vera.
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What is BCBSVT/TVHP Peg-Intron PA Form?
The BCBSVT/TVHP Peg-Intron PA Form is a prior authorization form required for the approval of Peg-Intron (peginterferon alfa-2b) treatment by Blue Cross Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP).
Who is required to file BCBSVT/TVHP Peg-Intron PA Form?
Healthcare providers prescribing Peg-Intron on behalf of a patient must file the BCBSVT/TVHP Peg-Intron PA Form to ensure the treatment is covered by the insurance.
How to fill out BCBSVT/TVHP Peg-Intron PA Form?
To fill out the BCBSVT/TVHP Peg-Intron PA Form, healthcare providers must provide patient information, medication details, treatment history, and supporting documentation that justifies the medical necessity of Peg-Intron therapy.
What is the purpose of BCBSVT/TVHP Peg-Intron PA Form?
The purpose of the BCBSVT/TVHP Peg-Intron PA Form is to obtain prior authorization from the insurance provider to cover the costs associated with Peg-Intron therapy, ensuring that the treatment meets the necessary clinical guidelines.
What information must be reported on BCBSVT/TVHP Peg-Intron PA Form?
The form must report the patient's personal information, the prescribing physician's details, diagnosis codes, previous treatment history, and any other relevant clinical information that supports the therapy's necessity.
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