Address: City: State: ZIP code: Inferferon Product Requested (Include Strength):

Transcription

1 Please complete this entire form and fax it to: If you have questions, please call This form contains multiple pages. Please complete all pages to avoid a delay in our decision. Allow at least 24 hours for review. Section A Member Information First Name: Last Name: Member ID: Address: City: State: ZIP Code: Phone: DOB: Allergies: Primary Insurance: Policy #: Group #: - Is the requested medication New or Continuation of Therapy? If continuation, list start date: - Is this patient currently hospitalized? Yes No If recently discharged, list discharge date: Section B - Provider Information First Name: Last Name: M.D./D.O. Address: City: State: ZIP code: Phone: Fax: NPI #: Specialty: Office Contact Name / Fax attention to: Section C - Medical Information (This form is for Hepatitis C Medications only; for all other drugs please submit a new form) Mavyret Epclusa Zepatier Directions of Use: Daklinza Sovaldi Harvoni Directions of Use: Olysio Incivek Victrellis Directions of Use:: Viekira Pak Viekira XR Directions of Use: Vosevi Technivie Other Agent Directions of Use: Ribavirin Product Requested (Include Strength): Inferferon Product Requested (Include Strength): Diagnosis (Please be specific & provide as much information as possible): Directions of Use: Directions of Use: ICD-10 CODE: Is this member pregnant? Yes No If yes, what is this member s due date? THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS WITH HEPATITIS C All supporting labs and chart documentation is required for medical review of this request. Genotype (Must submit supporting lab documentation) Genotype 1 Genotype 2 Genotype 3 Genotype 4 Genotype 5 Genotype 6 Other Gentoype (Must Specify): Prescriber Specialty: Hepatologist Gastroenterologist Infectious Disease Specialist Transplant Specialist Other (Must Specify): - Has this patient been treated for Hepatitis C previously? Yes No If Yes, please provide details of previous therapy including names of medications used, dates of therapy, and outcome of treatment / reason for discontinuing:

2 Section D Previous Medication Trials Trial Regimen (List all medications tried with each trial) Dates of Therapy Treatment Complete Outcome of Treatment or Reason for Discontinuation Clinical and Drug Specific Information ***Please Note: All labs and/or medical records addressed below MUST be submitted*** - Is the patient actively abusing alcohol or IV drugs, or has a history of abuse? Yes No - Is there documentation of prescriber counseling regarding the risks of alcohol or IV drug abuse, in patients with history of alcohol or IV drug abuse? Yes No - If patient is actively abusing IV drugs, has an offer of a referral for substance use disorder treatment been given? Yes No - Does the patient have a history of intolerance or contraindication to Mavyret? Yes No (If yes, complete Section D above with medication information, duration, date of trial, and reason for discontinuation) - Is Mavyret therapy not appropriate per the AASLD (American Association for the Study of Liver Diseases) guidance? Yes No - Is the patient currently on any of the following medications: Yes No (check which applies) Daklinza Epclusa Harvoni Olysio Sovaldi Technivie Viekira Pak Viekira XR Vosevi Zepatier - Please select one of the following: Compensated Decompensated Patient does not have cirrhosis - What is the duration of treatment: 8 weeks 12 weeks 16 weeks 24 weeks Other, list: weeks - Has the patient initiated, or completed, the Hepatitis B vaccination series? Yes No - If the patient has not initiated, or completed, the Hepatitis B vaccination series, ALL of the following Hepatitis B screening test results must be submitted: HBsAb HBsAg HBcAb HBcAg - Is the patient positive for Hepatitis BsAg or cab or cag? Yes No - If any of the above are positive, is there documented completion of quantitative HBV DNA? Yes, and it was detectable Yes, and it was not detectable No - If HBV DNA is detectable, will the patient being treated for Hepatitis B? Yes No - If the patient is negative for Hepatitis BSAg or cab, or cag, is the patient being vaccinated against hepatitis B? Yes No - Does the patient have a documented HIV screening (HIV Ag/Ab)? Yes No - Was the patient confirmed positive by HIV-1/HIV-2 differentiation immunoassay? Yes No - Is one of the following true: Yes No (check which applies) Patient is being treated for HIV Patient is not being treated for HIV, and the medical record documents the rationale for not being treated List rationale: None of the above

3 Requests for Mavyret: - Is the patient without cirrhosis or has compensated cirrhosis (Child-Pugh A)? Yes No - Which of the following does the patient have? Yes No (check which applies) Genotype 1, 2, 3, 4, 5, or 6 and treatment naïve Genotype 1 and treatment-experienced (previously treated) with an NS5A inhibitor without prior treatment with an NS3/4A protease inhibitor Genotype 1 and treatment-experienced (previously treated) with an NS3/4A protease inhibitor without prior treatment with an NS5A inhibitor Genotype 1, 2, 3, 4, 5, or 6 and treatment-experienced (previously treated) with interferon, pegylated interferon, ribavirin, and/or sofosbuvir, but no prior treatment experience with an HCV NS3/4A protease inhibitor or NS5A inhibitor Requests for Daklinza: - Is Mavyret therapy not appropriate per the AASLD (American Association for the Study of Liver Diseases) guidance? Yes No Patient without cirrhosis, for Daklinza + sofosbuvir for 12 weeks Patient with compensated (Child-Pugh A) cirrhosis, for Daklinza + sofosbuvir for 12 weeks Patient with decompensated (Child-Pugh B or C) cirrhosis, for Daklinza + sofosbuvir + ribavirin for 12 weeks Patient who is post-transplant, for Daklinza + sofosbuvir + ribavirin for 12 weeks Patient with compensated (Child-Pugh A) cirrhosis, for Daklinza + sofosbuvir + ribavirin for 12 weeks Requests for Epclusa: Patient without cirrhosis, for Epclusa for 12 weeks Patient with compensated cirrhosis (Child-Pugh A), for Epclusa for 12 weeks Patient with decompensated cirrhosis (Child-Pugh B or C), for Epclusa + ribavirin for 12 weeks Requests for Harvoni: - What is the patient s weight?: kg (Required) Genotype 1 treatment-naïve without cirrhosis or with compensated cirrhosis (Child-Pugh A), for Harvoni x 12 weeks Genotype 1 treatment-experienced without cirrhosis, for Harvoni x 12 weeks Genotype 1 treatment-experienced with compensated cirrhosis (Child-Pugh A), for Harvoni x 24 weeks Genotype 1 treatment-naïve or treatment-experienced with decompensated cirrhosis (Child-Pugh B or C), for Harvoni + ribavirin x 12 weeks Genotype 1 or 4 treatment-naïve or treatment-experienced with liver transplant without cirrhosis, or with compensated cirrhosis (Child-Pugh A), for Harvoni + ribavirin x 12 weeks Genotype 4, 5, or 6 treatment-naïve or treatment-experienced without cirrhosis or with compensated cirrhosis, for Harvoni x 12 weeks Requests for Olysio: Genotype 1 without cirrhosis, for Olysio and sofosbuvir x 12 weeks Genotype 1 with compensated cirrhosis (Child-Pugh A), for Olysio and sofosbuvir x 24 weeks Genotype 1 or 4 without cirrhosis or with compensated cirrhosis (Child-Pugh A) with or without HIV-1 co-infection, for Olysio and Peg-IFN-alfa and ribavirin x 12 weeks

4 Requests for Sovaldi: - What is the patient s weight?: kg (Required) Genotype 1 or 4, treatment naïve without cirrhosis or with compensated cirrhosis (Child-Pugh A), for Sovaldi + peg-interferon alfa + ribavirin x 12 weeks Genotype 2, treatment naïve or treatment experienced without cirrhosis or with compensated cirrhosis (Child-Pugh A), for Sovaldi + ribavirin x 12 weeks Genotype 3, treatment naïve or treatment experienced without cirrhosis or with compensated cirrhosis (Child-Pugh A), for Sovaldi + ribavirin x 24 weeks Genotype 1 and interferon ineligible, for Sovaldi + ribavirin x 24 weeks, List reason for interferon ineligibility: Hepatocellular carcinoma awaiting liver transplantation, for Sovaldi + ribavirin x up to 48 weeks or until liver transplantation, whichever occurs first, List date of liver transplant: Requests for Technivie: Patient without cirrhosis or with compensated cirrhosis, for Technivie + ribavirin x 12 weeks Treatment naïve patient who cannot take or tolerate ribavirin, for Technivie x 12 weeks, List ribavirin intolerance or contraindication: Requests for Zepatier: Genotype 1a treatment-naïve or PegIFN/RBV experienced without baseline NS5A polymorphisms*, for Zepatier x 12 weeks Genotype 1a treatment-naïve or PegIFN/RBV experienced with baseline NS5A polymorphisms*, for Zepatier + ribavirin x 16 weeks Genotype 1b treatment-naïve or PegIFN/RBV experienced, for Zepatier x 12 weeks Genotype 1a or 1b PegIFN/RBV/NS3/4A protease inhibitor experienced, for Zepatier + ribavirin x 12 weeks Genotype 4 treatment naïve, for Zepatier x 12 weeks Genotype 4 PegIFN/RBV experienced, for Zepatier + ribavirin x 16 weeks Requests for Vosevi: - Is the patient without cirrhosis or has compensated cirrhosis (Child-Pugh A)? Yes No - Which of the following applies to the patient? Yes No (check which applies) Genotype 1 and had virologic failure after completing previous treatment of at least 4 weeks duration with an HCV regimen containing an NS5A inhibitor Genotype 2, 3, 4, 5, or 6, and had virologic failure after completing previous treatment of at least 4 weeks duration with an HCV regimen containing an NS5A inhibitor Genotype 1a, and had virologic failure after completing previous treatment of at least 4 weeks duration with an HCV regimen containing sofosbuvir without an NS5A inhibitor Genotype 3, and had virologic failure after completing previous treatment of at least 4 weeks duration with an HCV regimen containing sofosbuvir without an NS5A inhibitor. - Has the patient been previously treated with an NS3/4A inhibitor? Yes No

5 Requests for Viekira: Genotype 1a without cirrhosis, for Viekira + ribavirin for 12 weeks Genotype 1a with compensated cirrhosis, for Viekira + ribavirin x 24 weeks. Genotype 1b, with or without compensated cirrhosis, for Viekira x 12 weeks Requests for Regimens not listed: - Is the requested regimen in accordance with AASLD recommendations, based on patient genotype and characteristics? Yes No Physician Signature: Confidentiality Notice: This transmission contains confidential information belonging to the sender and UnitedHealthcare. This information is intended only for the use of UnitedHealthcare. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action involving the contents of this document is prohibited. If you have received this telecopy in error, please notify the sender immediately. Website: uhccommunityplan.com Date: