Get the free Maraviroc (Selzentry™) Prior Authorization Form

This form is utilized to request initial authorization for Maraviroc (Selzentry™) coverage under the HealthPAC HIV program, requiring details about the patient and tropism assay results.

How to fill out maraviroc selzentry prior authorization

How to fill out Maraviroc (Selzentry™) Prior Authorization Form

1. Obtain the Maraviroc (Selzentry™) Prior Authorization Form from your healthcare provider or insurance company.
2. Fill in patient information, including full name, date of birth, and insurance details.
3. Provide the prescribing physician's information, including name, contact details, and National Provider Identifier (NPI).
4. Indicate the diagnosis for which Maraviroc is being prescribed, including any relevant medical history.
5. Specify the prescribed dosage and frequency of administration.
6. Include any pertinent laboratory results or supportive documentation that may strengthen the request.
7. Sign and date the form, authorizing the release of medical information to the insurance provider.
8. Submit the completed form to your insurance company, either via fax or online submission, as per their requirements.
9. Follow up with the insurance company to confirm receipt and answer any additional questions they may have.

Who needs Maraviroc (Selzentry™) Prior Authorization Form?

1. Patients who are prescribed Maraviroc (Selzentry™) for the treatment of HIV.
2. Healthcare providers who need to ensure that their patients' treatments are covered by insurance.
3. Patients who have insurance plans that require prior authorization for specific medications.

People Also Ask about

What is the dosing for maraviroc?

Dosing Adults—150, 300, or 600 milligrams (mg) two times a day, taken together with other medicines. Children 2 years of age and older—Dose is based on body weight and must be determined by your doctor. Children younger than 2 years of age—Use and dose must be determined by your doctor.

Is maraviroc still used?

Selzentry (maraviroc): Distribution of the 25mg tablet (120 count) and 75mg tablet (120 count) is expected to cease by January 1, 2024. Selzentry 150mg, Selzentry 300mg, and Selzentry Oral Solution will still be available.

What is the dosing schedule for ranolazine?

Ranolazine is available as 500 mg and 1000 mg extended-release tablets. Dosing should begin at 500 mg twice daily and be titrated to 1000 mg twice daily as tolerated. The maximum recommended dose is 1000 mg twice a day. The tablets are film-coated and not scored; they should not be crushed, broken, or chewed.

How is maraviroc taken?

Take maraviroc by mouth with or without food. Swallow maraviroc tablets whole. Do not chew the tablets. Maraviroc oral solution is packaged in a convenience combination kit that contains 1 bottle of maraviroc oral solution and supplies needed to take each dose.

What is Selzentry used for?

Maraviroc (brand name: Selzentry) is a prescription medicine approved by the U.S. Food and Drug Administration (FDA) for the treatment of HIV in adults and children weighing at least 4.4 lb (2 kg).

What is the dosing for ritonavir?

For oral dosage form (tablets): For treatment of mild to moderate COVID-19: Adults and children 12 years of age and older weighing 40 kilograms (kg) or more—300 milligrams (mg) (2 tablets) of nirmatrelvir and 100 mg (1 tablet) of ritonavir taken as a single dose 2 times a day for 5 days.

What is the generic name for maraviroc?

Maraviroc (brand-named Selzentry, or Celsentri outside the U.S.) is a chemokine receptor antagonist drug developed by the drug company Pfizer that is designed to act against HIV by interfering with the interaction between HIV and CCR5.

What is the dosing for Phenoxybenzamine?

The initial phenoxybenzamine dose is once to twice daily, usually 10 mg, with an increase of 10 to 20 mg in divided doses every two to three days as needed as a means to controlling blood pressure and spells.

For pdfFiller’s FAQs

What is Maraviroc (Selzentry™) Prior Authorization Form?

The Maraviroc (Selzentry™) Prior Authorization Form is a document required by insurance companies to approve coverage for the medication Maraviroc, which is used to treat HIV infection.

Who is required to file Maraviroc (Selzentry™) Prior Authorization Form?

Healthcare providers, such as physicians or prescribers, are required to file the Maraviroc (Selzentry™) Prior Authorization Form on behalf of the patient to obtain insurance approval for the medication.

How to fill out Maraviroc (Selzentry™) Prior Authorization Form?

To fill out the Maraviroc (Selzentry™) Prior Authorization Form, the healthcare provider must provide patient demographics, details of the patient's medical history, specific information regarding the prescribed treatment regimen, and the justification for using Maraviroc.

What is the purpose of Maraviroc (Selzentry™) Prior Authorization Form?

The purpose of the Maraviroc (Selzentry™) Prior Authorization Form is to ensure that the use of the medication is medically necessary and meets the insurer’s criteria for coverage, thereby facilitating access to treatment for the patient.

What information must be reported on Maraviroc (Selzentry™) Prior Authorization Form?

The information that must be reported on the Maraviroc (Selzentry™) Prior Authorization Form includes patient identification details, prescribing physician information, medical history, previous treatment attempts, current health status, and reasons for requesting Maraviroc.