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Hepatitis C Best Practice Treatment Protocols

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Medication Referral Form

Click here to download the HepCare Pharmacy Hepatitis C Referral Form.

Click here to download the HepCare Pharmacy Gastroenterology and Hepatology Referral Form.

Click here to download the HepCare Pharmacy Rheumatology Referral Form.

Click here to download the HepCare Pharmacy Dermatology Referral Form..

Once the completed form is received by our professional staff, we will:

  • Verify health insurance coverage/benefits [including co-pays] and file the claim with the insurance carrier;
  • Inform your office of patient prescription status throughout the process and provide real-time referral status tracking;
  • Bill all forms of medication coverage including private insurance, Medicare Part B & D, and all Medicaid plans;
  • Facilitate enrollment in manufacturer co-pay, discount voucher, and foundation assistance programs to help manage out-of-pocket expenses for patients who are experiencing difficulty paying for the medications;
  • Guide you through the Pharmaceutical Patient Assistance Programs [PAP] application process and follow up regularly with both the patient and PAP program until a resolution is reached;
  • Call patients to optimize medication adherence through side effect reporting and monitoring, adherence assessment, reminders for refills, laboratory visits, and provider appointments;

If we are unable to process the prescriptions, we will provide a complete transfer of the prescription to the designated pharmacy as set by the patient’s insurance. In the event that a transfer is needed, we will notify you of this transaction and provide status updates, whenever possible.


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