HEPATOLOGY
New Orleans, LA: toll free 888.355.4191 toll free fax 888.355.4192
tlcrxpharmacy.com
DATE: _______________ NEEDS BY DATE: ______________ SHIP TO: o PATIENT o OFFICE o OTHER _______________________________________________________________
PATIENT INFO
PRESCRIBER INFO
Patient Name
Prescriber Name
Address
DEA #
City, State, Zip
Address
Main Phone
Alternate Phone
NPI #
City, State, Zip
Social Security #
Phone
Date of Birth
License #
o Male
o Female
Fax
Contact Person
INSURANCE: PLEASE FAX COPY OF PRESCRIPTION CARD & MEDICAL CARD FRONT & BACK
CLINICAL INFORMATION
o 070.54 Chronic Hepatitis C o 572.2 Hepatic Encephalopathy o 155.0 Hepatocellular Carcinoma o Other: _________________________________________________________
Genotype: o 1 o 1a (Q80K Polymorphism: o Yes o No) o 1b o 2 o 2a o 2b o 3 o 3a o 3b o 4 o 4a o 4b Viral Load:_________________ IU/ml Viral Load Date :__________
o Treatment Naive
o Previously Treated: Prior treatment used: ______________________________________________________
o Non-Responder
Duration of previous therapy: From _____________________ to ___________________ Total of: _________ months HIV Coinfected: o Yes o No
Compensated Liver Disease: o Yes o No Cirrhosis: o Yes o No Metavir Score: ______
Solid Organ Transplant recipient: o Yes o No
o Take 1 tablet by mouth daily with or without food
oSovaldi® 400mg Tablet o Take 1 tablet by mouth once per day
HBV Coinfected: o Yes o No
Awaiting Liver Transplant?: o Yes o No
PRESCRIPTION INFORMATION
oHarvoni® 90mg/400mg Tablet
o Responder/Relapser
o Take 2 tablets (ombitasvir/paritaprevir/ritonavir) once daily in
the morning and 1 tablet (dasabuvir) twice daily in the morning and evening with a meal as directed by the Pak
oModeriba 200mg Tablet
o 600mg AM and 600mg PM (1200mg) o 600mg AM and 400mg PM (1000mg)
oRibavirin 200mg Tablet
o 400mg AM and 400mg PM (800mg)
o 400mg AM and 200mg PM (600mg)
oRibavirin 200mg Capsule
o Other: Take ___________ mg AM and ________________ mg PM
QUANTITY REFILLS
28 day supply ___________
28 day supply ___________
oViekira Pak® 28 day supply
___________
28 day supply ___________
oRiba-Pak® (ribavirin)
o 600mg AM and 600mg PM (1200mg)
o 600mg AM and 400mg PM (1000mg)
oModeriba Pak® (ribavirin)
o 400mg AM and 400mg PM (800mg)
o 400mg AM and 200mg PM (600mg)
oOlysio® 150mg Capsule
o Take 1 capsule by mouth once per day with food
28 day supply ___________
o Pegasys® o PFS o ProClick
Inject: o 180mcg subcutaneously weekly o 135mcg subcutaneously weekly o 90mcg subcutaneously weekly
28 day supply ___________
oPeg-Intron® Redipen
Less than 88lbs
89-111
Less than 40kg 50mcg/0.5 ml
40-50 80mcg/0.5 ml 28 day supply ___________
o 50mcg (0.5 ml) subcutaneously weekly
o 64mcg (0.4 ml) subcutaneously weekly
112-133
51-60 o 80mcg (0.5 ml) subcutaneously weekly
134-166
61-75 120mcg/0.5 ml o 96mcg (0.4 ml) subcutaneously weekly
167-187
76-85 o 120mcg (0.5 ml) subcutaneously weekly
greater than 187 greater than 85 150mcg/0.5 ml o 150mcg (0.5 ml) subcutaneously weekly
28 day supply ___________
o Procrit
Inject: o 40,000 units subcutaneously every week o other: ______________________________
28 day supply
___________
o Neupogen SingleJect
Inject: o 300mcg o 480 mcg subcutaneously o every week o twice weekly o three times weekly
28 day supply
___________
o Xifaxan 550mg Tablet
o Take 1 tablet by mouth twice daily
30 day supply ___________
By signing this form and utilizing our services, you are authorizing TLCRxTM and it’s
employees to serve as your prior authorization designated agent in dealing with
medical and prescription insurance companies.
**indicate previously failed therapy (Lactulose) _______
_______________________________________________________________ _______________
Prescriber’s Signature (no stamps)
If Brand required check o DAW Date
IMPORTANT NOTICE: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, privileged property or exempt from disclosure under applicable law. If you are
not the named addresses you should not disseminate, distribute or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately.
12-22-2014 LA