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Washington State AIDS Drug Assistance Program (Early Intervention Program): Prior Authorization Forms

Fuzeon

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

Aptivus

Please make sure to fill out EITHER section 1 OR 2 of the application.
Download PDF

Pegylated Interferon

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

Baraclude

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

Anabolic Steroids

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

Maraviroc (Selzentry™)

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

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Trofile™ Lab Assay

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

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