Hepatitis C Agents Form - Children'S Medical Services Network
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CHILDREN’S MEDICAL SERVICES NETWORK
HEPATITIS C AGENTS
Note: Form must be completed in full.
An incomplete form may be returned.
Recipient’s Medicaid ID#
Date of Birth (MM/DD/YYYY)
/
/
Recipient’s Full Name
Prescriber’s Full Name
Prescriber License # (ME, OS, ARNP, PA)
Prescriber Phone Number
Prescriber Fax Number
-
-
-
-
What is/are the requested medication(s)?
Daklinza
_______________ weeks
Sovaldi
_______________ weeks
Ribavirin*
_______________ weeks
Olysio
_______________ weeks
Peginterferon alfa**
_______________ weeks
Harvoni
_______________ weeks
Zepatier
_______________ weeks
Technivie
_______________ weeks
Other
_______________ weeks
*
___________________________________________
Ribavirin: Provide drug, strength, and directions:
**
Peginterferon alfa: Provide drug, strength and directions:
_________________________________________________________
(If prescribing non-preferred alternatives, please provide documentation of a medical reason why the patient is unable to take the preferred
medication)
PLEASE NOTE: VIEKIRA IS THE PREFERRED AGENT FOR GENOTYPE 1. IF THE DIAGNOSIS IS
ON FILE, THE RECEIPIENT IS 18 YEARS OR OLDER AND IS TREATMENT NAÏVE, THE CLAIM WILL
PAY FOR 12 WEEKS OF THERAPY WITHOUT A PRIOR AUTHORIZATION
Physician must submit all supporting documentation including lab results.
1.
Does the recipient have chronic hepatitis C?
Yes
No
2.
Is prescriber a hepatologist, gastroenterologist, infectious disease specialist, or transplant physician?
Yes
No
3.
If no, is the prescribing physician in consultation with a specialist indicated above?
Yes
No
4.
What is the recipient’s HCV genotype? (attach genotype test results)
1a
1b
2
3
4
5
6
•
If genotype 1a, NS3 Q80K polymorphism? (simeprevir requests only)
Yes
No
•
If genotype 1a, please list any NS5A polymorphisms: (must submit documentation)
M28
Q30
L31
Y93
5.
Has the recipient been previously treated with HCV therapy?
Yes
No
If yes, please specify date, regimen and duration: __________________________________________
If yes, please document response to therapy:
Null responder
Partial responder
Relapser
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