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Hepatitis C Enrollment Form
Houston Location
4126 Southwest Frwy Ste 100 Houston, TX. 77027
Phone (800) 650-0107
Fax to: (888)478-4541
PATIENT
INFO
• Date:
• Ship To:
Name:
□ Patient □
□
DOB:
Address:
□
Male
Office
Female
City, State, Zip:
Telephone:
Other Phone:
INSURANCE INFO:
Diagnosis (ICD-9) Code:
□
SS#:
PLEASE FAX COPY OF INSURANCE CARD (FRONT & BACK) & PATIENT DEMOGRAPHIC SHEET
070.54 Hepatitis C (chronic) • Date of Diag:
• HCV RNA (Baseline)
CLINICAL INFORMATION
• Date Needed:
• Weight:
IU/mL • HCV RNA (after ___ wks treatment)
□ 1a □ 1b □ 2 □ 3 □ 4 □
• Has patient been previously treated for Hepatitis C? □ Yes □
□ Yes □
• Is patient ineligible for treatment with Interferon?
• HCV Genotype:
□6
5
kg/lb
IU/mL
□ NKDA
• Allergies:
• Date of lab:
• Length of treatment:
• Pre-treatment ALT:
No • Other medications: ________________________________________
No
• If yes, reason for ineligibility:
• Liver Biopsy Results: ___________________/Date: _______________
_______________________________
• Fibroscan Results: ___________________/Date: __________
• Does patient have any of the following findings (based on HCV Guidelines - www.hcvguidelines.org):
HIGHEST PRIORITY:
Advanced Fibrosis (Met F3)
Compensated cirrhosis (Met F4)
Post-liver transplant
□
□
□
□ Type 2/3 essential mixed cyroglobulinemia w/ end-organ manif.
□ Proteinura □ Nephrotic syndrome □ Glomerulonephritis
HIGH PRIORITY:
□ Fibrosis (Met F2) □ HIV co-infection □ Hepatitis B co-infection □ Other co-existent liver disease (eg, NASH)
□ Debilitating fatigue □ Type 2 Diabetes mellitus □ Porphyria cutanea tarda OTHER: □ Q80K polymorphism □ Metavir F0-F1
(eg, vasculitis)
• IF TAKING RIBAVIRIN, is the patient (or patient's partner) pregnant or unwilling to use adequate contraception, or is there a history of
hemoglobinopathies or renal insufficiency (crcl < 50mL/min)? □ Yes □ No
COMBINATION THERAPIES - HARVONI
COMBINATION THERAPIES - SOVALDI/OLYSIO
□ 1. SOVALDI™ 400mg (sofosbuvir) |
□ HARVONI® 90mg/400 (ledipasvir/sofosbuvir)
• Directions: □ 1 tab po QD
□ Qty: 28-day supply
mg
• Choose Patient type below:
□ GTP 1: Tx. Naïve with or without cirrhosis
□ GTP 1: Tx. Experienced, no cirrhosis
□ GTP 1: Tx. Experienced, with cirrhosis
Tx. Naïve, no cirr, HCV RNA < 6 mi u,GTP 1*
□
□ GTPs 4 & 6: Tx. Naïve or Tx. Experienced
□ Other:
PRESCRIPTION INFORMATION
*Prescriber decision - 8 weeks of treatment can be
considered in tx naïve pts with HCV RNA < 6mill IU/ml
Tx. Duration Refills
12 weeks
2
12 weeks
2
24 weeks
5
8 weeks
1
12 weeks
2
• Qty: _______ □ 28-day supply
• Choose Patient type below:
Tx. Duration Refills
*12 weeks may be considered based on prior treatment
history
□ RIBAVIRIN:
12 weeks
2
24 weeks
5
12 weeks
2
12 weeks
2
24 weeks
5
12 weeks
2
If approp, please choose product under 'RIBAVIRIN'
**For patients with HIV co-infection, please follow mono-infection guidelines
OTHER MEDICATIONS
□ Medication: ______________________
• Choose Patient type below:
□
□ GTP 1: Cirrhosis/Tx. Naïve or Tx. Experienced
□ GTP 4: Tx. Naïve or Tx. Experienced
□ Other:
GTP 1: No Cirrhosis/Tx. Naïve or Tx. Exper.
• Choose Patient type below:
PRESCRIBER
INFORMATION
2
24 weeks
5
12 weeks
2
Directions: □ 1 tab po QD
□
□ GTP 2: Tx. Naïve, cirrhosis; Tx. Experienced
□ GTP 3: Tx. Naïve or Tx. Experienced
□ GTP 4: Tx. Naïve or Tx. Experienced
□ Other:
GTP 2: Tx. Naïve, no cirrhosis
Tx. Duration
Refills
12 weeks
2
16 weeks
3
24 weeks
5
24 weeks
5
RIBAVIRIN
□ RIBAPAK™
□
□ <75kg/172lbs 1000mg/day
□ ≥75kg/173lbs 1200mg/day
□ Other:
• Qty:
MODERIBA™ tablet dose pack
Take 600mg po qAM and 400mg po qPM
Take 600mg po qAM and 600mg po qPM
□ 28-day supply; □ Other: _____
□ tablets
• Refills: ______
□ capsules
Directions: Take _____ tabs/caps po qam and _____ tabs/caps po qpm
• Qty:
28-day supply;
Other: _____ • Refills: ______
□
Prescriber's Name:
□
Contact person:
Telephone:
Fax:
Office Address:
Prescriber's Signature
Refills
12 weeks
□ 2. RIBAVIRIN: Please choose product under 'RIBAVIRIN'
RIBAVIRIN 200mg
Strength: ______
• Directions: _____________________; Qty: _____; Refills: ____
NPI#:
Tx. Duration
Qty: _______ □ 28-day supply
(2 paritaprevir/ritonavir/
ombitasvir tabs po qam & 1
dasabuvir tab po BID)
□ GTP 1a, no cirrhosis (add ribavirin)
GTP 1a, with cirrhosis (add ribavirin)*
□
□ GTP 1b, no cirrhosis
□ GTP 1b, with cirrhosis (add ribavirin)
□ Post-liver transplant, GTP 1a or 1b (add riba)
□ GTP 4: Tx. Naïve or Tx. Experienced (add riba)
□ Other:
Directions: □ 1 cap po QD
Qty: _______ □ 28-day supply
□ 1. SOVALDI™ 400mg (sofosbuvir) |
(paritaprevir 75/ritonavir 50-ombitasvir 12.5mg & dasabuvir 250mg)
• Directions: □ Take as directed on PAK po w/ food
□ 2. OLYSIO™ 150mg (simeprevir) |
COMBINATION THERAPIES - SOVALDI/RIBAVIRIN
COMBINATION THERAPIES - VIEKIRA PAK
□ VIEKIRA PAK™
Directions: □ 1 tab po QD
Qty: _______ □ 28-day supply
City:
License #:
State:
Zip:
Medicaid Provider #:
(DATE)
*I f brand drugs are preferred, handw rite "Brand M edically N ecessary" above
I authorize ReCept Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process.
IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone
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retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. REF 006Guided. R31. 1 15