Authorization to receive Fuzeon is given in six-month periods and access to Fuzeon is limited based on the availability of openings.
Please be sure to include any necessary lab measurements that show the patient’s viral load measurement, CD4 count and genotype resistance profile. Download PDF
Please make sure to fill out EITHER section 1 OR 2 of the application. Download PDF
Patients must submit a request for pegylated interferon thru the WA Washington State Department of Health Prescription Drug Program by first submitting this form to Ramsell Public Health Rx. Download PDF
Patients must fail therapy with both lamivudine and tenofovir prior to therapy with Baraclude. There must be documented treatment failure evidenced by a (+) Hep B DNA and a (+) Hep BeAg (Hep B envelope antigen). Download PDF
Please fill out Form A for the initial approval only and Form B for subsequent refill requests.
Please be sure to include documented dates and dosage of testosterone therapy when applying for the initial approval. Download PDF
Selzentry is only covered for patients resistant to alternative antiretroviral treatment regimens and who exhibit CCR5 co-receptor status.
A copy of the most recent HIV RNA lab must also be submitted with the application.
The Selzentry (maraviroc) prior authorization access form must be faxed back to the program Pharmacy Benefit Manager, Ramsell Public Health Rx at 800-848-4241. Download PDF
The Washington State Department of Health Early Intervention Program (EIP) covers the Trofile™ Lab Assay for Washington EIP patients with no other insurance coverage. This form must be faxed back to the Washington EIP program at 360-661-2216. Download PDF
Nationwide Program Benefits Individuals by Providing Access to Prescription Drugs at a Discount; Cost-Savings can Range from 10 to 85 Percent
Oakland, Calif. and Greenwood Village, Colo., August 5, 2008 - Ramsell Public Health Rx, a pharmacy benefits manager and information management company, and its partner, HealthTrans, a pharmacy benefit administrator, will offer a nationwide drug discount program tailored to help uninsured and underinsured individuals. Named the Ramsell Pharmacy Discount Card Program, this initiative provides prescription drug discounts to individuals or families regardless of current health condition, age or insurance status, allowing for an average of 10 to 85 percent savings on brand and generic medications at more than 58,000 pharmacies.