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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 4932C 09045 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 4932C 09045 RxUM_HepC_MRF_Revised 0815 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 4932C 09045 RxUM_HepC_MRF_Revised 0815