1. health and fitness
2. disease
3. aids and hiv

FIDELIS CARE MEDICATION REQUEST
FORM FOR HEPATITIS C (HCV) AGENTS (10/15/2014)
Copies of this form and additional information available at http://www.fideliscare.org/pharmacy
Complete form and fax to 1-877-533-2405. Fidelis Care will notify you within 3 business days as to what determination has been
made. If you have any questions, please dial 1-888-FIDELIS (1-888-343-3547) and follow the appropriate prompts. To avoid
unnecessary delays, PLEASE ENSURE THAT YOU COMPLETE THE FORM IN ITS ENTIRETY AND PRINT NEATLY
TO HELP EXPEDITE THE DRUG COVERAGE REVIEW PROCESS.
Member Name__________________________________________ID#_____________________________DOB______________________
Age____________________ Height_______________________Weight_____________________ Sex______________________________
Prescriber name_____________________________________________________ Contact Person _______________________________
Phone number_________________________ Ext______________ Fax_______________________ County_________________________
Address_______________________________________________ City________________________ State__________ Zip ____________
Specialty
Hepatologist
Gastroenterology
Transplant physician
Infectious Disease
HCV Clinical Experience
Other ______________
Management of ≥ 20 patients with HCV infection within last 12 months; and
Treatment for HCV in ≥ 10 patients within last 12 months; and
Obtained ≥ 10 HCV-related CME credits in the last 12 months; OR
Management & treatment of HCV infection in partnership (i.e. consultation, preceptorship, or via
telemedicine) with an experienced HCV provider who meets the above criteria (include name below)
Collaborating Provider Name ________________________________ Phone # __________________
1.
Hepatitis C Genotype: (hard copy required; please attach)
1a
2.
What is the patient’s hepatic fibrosis stage? (hard copy required; please attach)
0
1
2
3
4
This may include: (1) liver biopsy confirming a METAVIR score, (2) Transient elastography, Fibroscan, score, (3) FibroSure
score, (4) APRI score, and/or (5) radiological imaging.
3.
Does the patient have any of the following? (please attach chart notes to document if patient has any of the following conditions)
Cirrhosis/decompensated liver disease (documentation/labs required )
HBV (confirmatory results required)
1b
2
3
4
5
6
Severe renal impairment (renal function labs required)
HIV (viral load within past 6 months required)
Cryoglobulinemia with end-organ manifestation (CBC, ESR, and renal function labs required)
4.
Prior treatment status:
Treatment-Naive
Relapser with use of the following: _________________________________
______________________________________________________________________________________________________________
5.
Is the patient currently using P-gp inducers (such as rifampin and St. John’s wort), anticonvulsants, or other drugs (prescribed
or over-the-counter) that may affect Hep C treatment?
Yes
No
6.
If patient is a female of child-bearing potential, does the patient have a negative pregnancy test collected within 30 days prior to
treatment initiation?
Yes; (hard copy required or noted in charts for Hep C drugs, with exception of Harvoni)
No
N/A
7.
Has the patient demonstrated treatment readiness and the ability to adhere to the requested drug regimen?
Note that a lapse in therapy of ≥ 14 days is grounds for Fidelis Care to discontinue treatment.
8.
Has the patient verbally or in writing committed to planned course of treatment, including anticipated blood tests and visits
during and after treatment?
Yes; (chart notes must be submitted to document patient acknowledgement)
No
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Yes
No
Continued on second page
9.
Has the patient acknowledged that lost, stolen, destroyed, or inappropriately used supplies are not subject to replacement by
Fidelis Care?
Yes
No
10. Requested Medications †
Sovaldi 400 mg tablet
Olysio 150 mg tablet
Harvoni 90-400 mg tablet
Ribavirin tablets*
Ribavirin capsules*
Pegintron 50 mcg kit
Pegintron 80 mcg kit
Pegintron 120 mcg kit
Pegintron 150 mcg kit
Pegintron 50 mcg Redipen
Pegintron 80 mcg Redipen
Pegintron 120 mcg Redipen
Pegintron 150 mcg Redipen
Other _____________________
Other _____________________
Directions for use: _____________________________________________________________________________________________
_____________________________________________________________________________________________________________
* Please note generic ribavirin is the preferred product (Ribapak and branded formulations of ribavirin are non-formulary)
† Clinical rationale for an interferon-free regimen for genotypes 1 & 4 with Sovaldi required with documentation of contraindications
11. Expected total duration of therapy:
8 weeks
12 weeks
24 weeks
Other (please attach rationale separately) _________________
12. Baseline Laboratory Results within past 3 months (required for approval) - HARD COPIES MUST BE ATTACHED
Lab Date: ___________ Viral Load (VL):___________________IU/mL
Lab Date: ___________ AST:__________ ALT:__________
13. IMPORTANT – FOLLOW-UP LABS: Hep C regimens are approved based on therapy appropriateness on initial review for a 1-2
month duration. Continued coverage for the remainder of the treatment requires a follow-up viral load (within the first 2-4 weeks of
treatment) to be sent to Fidelis by certain due dates following the initial prescription fill. Please carefully read the chart below to find the
due date required for your patient.




Treatment Duration
1st Approval Period
F/U VL
F/U VL Sent to FCNY
2nd Approval Period
≥12 weeks
8 weeks
Week 2 - Week 4
Before Week 6
Remaining duration
8 weeks (Harvoni only)
4 weeks
Week 2
Before Day 21 (3 weeks)
Remaining 4 weeks
If approved, I agree to require my patient to come in between Week 2 to Week 4 of treatment (as appropriate; see above table) to draw
labs for evaluation of adherence and therapy effectiveness in order to continue therapy. I will also have the results forwarded to Fidelis
Care for continued coverage of the remaining regimen supply.
If approved, I am aware that Fidelis Care will not replace medications that are lost, stolen, destroyed, or inappropriately used by the
patient and that the patient is responsible for the safekeeping of his/her medication supply.
If approved, I am aware that non-adherence to the medication compromises the effectiveness of the treatment and that a lapse in use of
14 days or more is grounds for discontinuation of the treatment regimen by the plan.
By signing below, I attest that all statements on this form are true to the best of my knowledge.
Prescriber's Signature _________________________________________________________
Date ___________________
Reminder Before Submitting (*see questions for details) – Prior Authorization Checklist
Completed form (provider information and questions #1-#12)
Chart notes
Laboratory results: Genotype, HCV RNA within 3 months
Fibrosis stage (question #2)
Documentation for other comorbidities (see question #3 for details)
If female, (-) pregnancy test results (question #6)
Patient adherence, readiness, and commitment acknowledgement
Plans for follow-ups, including lab results
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