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.
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