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) - - - - - - - - - - - - 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.
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