Harvoni - The Health Plan

HARVONI
PRIOR AUTHORIZATION FORM
----Please complete all information---Member Name: ________________________________
DOB: __________________________
Member ID #: __________________________________
Date: _________________________
The Patient’s treatment status is: Treatment Naïve
 Prior Relapse
 Prior Partial Responder  Null Responder
Prior Hep-C Treatments: _____________________________________________________________________________________________
Reason for Failure: __________________________________________________________________________________________________
Documentation being submitted is current, with labwork from within the past 3 months.
Is the patient 18 years of age or older?
 Yes
 Yes
 No
 No
Has the patient been vaccinated against Hepatitis A and Hepatitis B
Is the patient pregnant, or is the male’s female partner pregnant?
 Yes
 No
 Yes  No
Has the patient been counseled on and agreed to comply with all the conditions stipulated on the Hepatitis-C Patient
Consent Form (see last page)?
 Yes  No
Is the patient co-infected with HIV?
 Yes
 No If yes, is the patient taking any protease inhibitors?
 Yes  No
For HIV co-infected patients, if patient is not taking antiretroviral therapy, is the CD4 count greater than 500 cell/mm 3?
 Yes
 No
For HIV co-infected patients, if patient is virologically suppressed 9e.g., HIV RNA <200 copies/mL), is CD4 count greater
than 200 cells/mm3?  Yes  No
Is the patient on any interacting drug therapies (e.g. tipranavir, ritonavir, rifampin, rifabutin, rifapentine, carbamazepine,
phenytoin, phenobarbital, oxcarbazepine, or St. John’s wort)?  Yes  No
Diagnosis/Dosing
Diagnosis (Include ICD9 Code)
Genotype (must present lab results)
Viral Load (Must present lab results
Please indicate fibrosis level (required) and submit supporting documentation with request:
□ F1
□ F3
Approvals will only be granted for levels of F3 or greater
□ F2
□ F4
Does the patient have hepatocellular carcinoma meeting Milan criteria (awaiting liver transplantation)?
 Yes
 No If yes, please provide the potential transplant date: __________________________________________
Accepted Regimens and Treatment Duration for Sovaldi® Combination Therapy in HCV Mono-Infected and HCV/HIV-1
Co-Infected Patients
***Please select one regimen below***
Select

Diagnosis
Approved Treatment
Regimen
Regimen Duration
Genotype 1, Treatment Naïve, HVCV RNA <6mil IU/ml
Harvoni
8 weeks
Harvoni
12 weeks
Harvoni
12 weeks
Sovaldi + peginterferon alfa +
12 weeks
without cirrhosis

Genotype 1, Treatment Naïve, HVCV RNA >6mil IU/ml
or with cirrhosis

Genotype 1, Treatment experienced w/out cirrhosis

Genotype 1, Treatment experienced with cirrhosis
ribavirin

Sovaldi + Olysio
12 weeks
Sovaldi + peginterferon alfa +
12 weeks
Genotype 1, Treatment experience with cirrhosis,
Interferon Ineligible

Genotype 1, HIV Co-Infection
ribavirin

Genotype 1, HIV Co-Infection, Interferon Ineligible
Sovaldi + ribavirin
24 weeks

Genotype 2
Sovaldi + ribavirin
12 weeks

Genotype 3
Sovaldi + peginterferon alfa +
12 weeks
ribavirin

Genotype 3, Interferon Ineligible

Genotype 4
Sovaldi + ribavirin
24 weeks
Sovaldi + peginterferon alfa +
12 weeks
ribavirin

Genotype 4, Interferon Ineligible
Sovaldi + ribavirin
24 weeks
Documentation supporting Interferon Ineligible regimens must be submitted with request.
Ribavirin (weight-based)
Medication being requested
Current Weight in Kilograms
Directions for use
Peginterferon-alfa
Medication being requested
Strength
Directions for use
Other pertinent information (attach additional pages if needed).: _______________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
PHYSICIAN INFORMATION:
Physician Name:
_____________________________________________
Address:
_____________________________________________
Telephone #:
_____________________________________________
_____________________________________________
Contact Person:
Physician Signature:
_____________________________________________
_____________________________________________
Member may be responsible for a copay
Fax requests to The Health Plan @ (740) 695-5297 or (888) 329-8471
Attn. Pharmacy Dept.
Patient Consent Form – Hepatitis C
I, _______________________________________________________________, have been counseled by my
healthcare provider on the following:



About the importance of not drinking alcohol or using illicit drugs during and after my treatment for
Hepatitis C, and
About how to avoid being re-infected with Hepatitis C during and after my treatment, and
About the importance of using two forms of birth control and I agree to have a pregnancy test
every month as ordered by my healthcare provider. I also understand that I must tell my
healthcare provider if I do become pregnant.
(Complete this section if applicable)
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

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-
-
-
-
-
-
-
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I also agree that I will complete the entire course of treatment and have laboratory tests before
starting, during and after completing treatment as ordered by my healthcare provider.
I attest that I have been drug and alcohol free for the past three months.
X_______________________________________________
Patient Signature
________________________________
Date
Please give this form to your physician to include with the Prior Authorization request for Hepatitis-C
treatment.