Hepatitis C Direct Acting Antiviral therapy Denial Reporting Form

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This form reports denials from payers to cover or pharmacies to dispense Hepatitis C Direct Acting Antiviral Medications and solicit information in case follow-up is needed. This form does not collect personal health information (PHI). Anyone filling out the form can choose to remain anonymous. Those filling out this form can list more than one Insurer, Pharmacy or Patient Assistance Program. You can reach us at Hepfreeaz@azdhs.gov.

Your Name & Email Address (Optional)

Number of Denials to Report?

Medication(s) Resulting in Denial? *

Glecaprevir / Pibrentasvir [Mavyret]

Sofosbuvir/ Velpatasvir [Epclusa]

Sofosbuvir/Ledipasvir-Sofosbuvir/Sofosbuvir-Velpatasvir [Vosevi]

Other:

Required

Is the denial source a health insurance company? *

Yes

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