Download Hepatitis C Medication Request Form

Hepatitis C
Medication Request Form
Fax to: 617-673-0988
Today’s date ___/___/___
This medication request form applies only to members of Tufts Health Together (MassHealth) and
Tufts Health Direct (an individual and small-group plan). Participating providers should use this form to request
authorization for Daklinza, Harvoni, Infergen, Pegasys, PegIntron, ribavirin, Sovaldi, Technivie and Viekira Pak.
Please call us at 888-257-1985 with any questions about medication requests.
WE CAN ONLY PROCESS COMPLETED FORMS
Member/Prescriber information
Member name:
Prescriber name (required):
Member ID #:
Prescriber specialty (required):
Member DOB:
DEA #: ________________________________________
NPI #: _________________________________________
Pharmacy used by member:
Prescriber contact name and telephone number (required):
Pharmacy telephone number, with area code:
Prescriber fax number, with area code:
Medication information
Requested drug(s):
 PegIntron (peginterferon alfa-2b), our preferred hepatitis C drug
Quantity: ________ per month
 Pegasys (peginterferon alfa-2a)
Quantity: ________ per month
Please provide clinical rationale for why PegIntron is contraindicated:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
 Ribavirin
 200 mg capsules
 200 mg tablets
 Other: ____________________
Quantity: _______ per month
If other, please provide clinical rationale for why you cannot prescribe ribavirin capsules or tablets:
________________________________________________________________________________
________________________________________________________________________________
 Sovaldi (sofosbuvir)
Quantity: ________ per month
 Harvoni (ledipasvir/sofosbuvir)
Quantity: ________ per month
 Viekira Pak
 Daklinza (daclatasvir)
 Technivie (ombitasvir, paritaprevir, and ritonavir
 Other: __________________________
Quantity: ________ per month
Requested duration of treatment: ___________ weeks
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Clinical information
Diagnosis:
 070.54 hepatitis C (chronic)
 Other: _______________
HCV Genotype: 1a 1b 2 3 4 5 6
Is the medication prescribed by a gastroenterologist, infectious disease specialist, or hepatologist?
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Does the patient have hepatitis B coinfection?
 Yes
 No
Does the patient have severe renal impairment or end-stage renal disease, or require dialysis?
 Yes
 No
Has the patient been previously treated for hepatitis C and failed treatment?
If yes, when? _____________ What treatment? ________________________________________
Is the patient currently receiving hepatitis C therapy?
If yes, current week of therapy: _____________________________________________________
 Yes
 No
 Yes
 No
Is there documentation of stage 3 or 4 hepatic fibrosis by one of the following? Please check all
that apply:
 Liver biopsy confirming METAVIR score of F3 or F4, or alternative scoring equivalent
 Transient elastography (Fibroscan) score greater than or equal to 9.5 kPa
 Fibrotest (FibroSURE) score of greater than or equal to 0.58
 APRI score greater than 1.5
 Imaging study consistent with cirrhosis
 Physical findings or clinical evidence consistent with cirrhosis as attested by the prescriber
Is there documented evidence of chronic liver disease, or in the absence of chronic liver disease,
serologic evidence of persistent infection for at least six months?
Is the member ineligible to receive interferon defined by at least one of the following? If yes,
Please choose one:
 Autoimmune hepatitis or autoimmune disorders including but not limited to: dermatomyositis,
immune (idiopathic) thrombocytopenic purpura, inflammatory bowel disease, interstitial lung
disease, interstitial nephritis, polymyositis, psoriasis, rheumatoid arthritis, sarcoidosis, and
systemic lupus erythematosus
 Major depressive illness or history of
 History of psychosis, schizophrenia, bipolar disorder, schizoaffective disorder, or suicidal
ideation
 Uncontrolled seizures
 Moderate or severe retinopathy
 Poorly controlled diabetes
 Baseline neutrophil count below 1,500/ µL
 Baseline platelet count below 70,000/ µL
 Baseline hemoglobin below 10 g/dL
 Significant ischemic cardiac disease
 Prior intolerance or hypersensitivity (e.g., urticarial, angioedema, bronchoconstriction,
anaphylaxis, or Stevens-Johnson Syndrome) to interferon therapy
 Symptomatic hepatitis C induced cryoglobulinemia
 Preexisting cardiac disease
Does the patient have HIV coinfection?
HCV RNA levels:
Baseline (required): __________________________________ IU/mL Date of lab work: ___________
Week 4 of treatment: ________________________________ IU/mL Date of lab work: ___________
Week 8 of treatment: _______________________________ IU/mL Date of lab work: ___________
Week 12 of treatment: _________________________________ IU/mL Date of lab work: ____________
Week 24 of treatment: _________________________________ IU/mL Date of lab work: ____________
Post-therapy
12 weeks after completion of treatment: _________________ IU/mL Date of lab work: ____________
Additional considerations
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Olysio Requests
Has there been confirmation that the patient does not have a genotype 1a with NS3
Q80K polymorphism?
 Unknown
 Yes
 No
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 Yes
 No
Is there documented attestation that the member has been assessed for potential nonadherence?
Has a treatment plan been developed and discussed with the patient?
Did the prescriber identify any potential issues with adherence?
 If yes, please describe: _______________________________________________________
 Yes
 Yes
 No
 No
 Yes
 No
Does the prescriber request help with adherence from the health plan?
 Yes
 No
 Yes
 No
 Yes
 Yes
 Yes
 No
 No
 No
 Yes
 No
 Yes
 No
Liver Transplant/Hepatocellular Carcinoma
Does the patient have a diagnosis of hepatocellular carcinoma that meets Milan criteria?
Is the member currently awaiting a liver transplant?
Does the member have decompensated liver disease? Please choose Child-Pugh Class: B or C
Is the patient being managed in a liver transplant center?
Substance Abuse History
Is the member actively participating in illicit substance abuse?
Adherence Treatment Plan and Attestation
Adjunctive Treatments
Is the member currently taking any medications that decrease the concentration of the agent requested
according to the prescribing information or clinical trials
Hepatitis C Patient Characteristics
Prior relapser
Compensated cirrhosis
Decompensated cirrhosis
Partial responder (i.e., ≥ 2 log reduction in HCV RNA at week 12, but detectable at end of prior course
of peginterferon/ribavirin therapy)
Null responder (i.e., < 2 log reduction in HCV RNA at week 12 to a prior course of
peginterferon/ribavirin therapy)
By checking the following box, I certify that applying the standard review time frame may seriously jeopardize my
patient’s life, health, or ability to attain, maintain, or regain maximum function.  Request for expedited review
I certify that the information provided is accurate and complete to the best of my knowledge, and I understand that any
falsification, omission, or concealment of material fact may subject me to civil or criminal liability.
Prescriber signature (STAMP NOT ACCEPTED)
Date
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