Hepatitis C Agents Form - Children'S Medical Services Network Page 2
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1
2CHILDREN’S MEDICAL SERVICES NETWORK
HEPATITIS C AGENTS
Note: Form must be completed in full.
An incomplete form may be returned.
6.
Does the recipient have chronic HCV with cirrhosis? (supporting documentation required)
Yes
No
If cirrhosis, what type?
Compensated
Decompensated
7.
Child Pugh Score:
A
B
C
8.
Does the recipient have hepatocellular carcinoma?
Yes
No
9.
Is the recipient HIV co-infected?
Yes
No
(Must have documented diagnosis and must submit most recent CD4 count – within last 6 months)
10. Liver transplant? (If yes, please specify date and submit supporting documentation)
Awaiting liver transplant (date): ___________________
No
Post-transplant
11. Indicate HCV RNA level (must submit lab results within the past three months for baseline).
Treatment week
Log10
Date Measured
Pre-treatment baseline
12. Has the recipient committed to the documented planned course of treatment,
Yes
No
inclusive of anticipated blood tests and physician visits, during and after treatment?
13. For ribavirin therapy: If the patient is a female of childbearing potential, has a negative
Yes
No
pregnancy test within 30 days of initiating therapy been submitted? (Must submit results of test)
14. Has recipient abstained from illicit drugs and/or alcohol consumption for a minimum of 1 month?
Yes
No
(Must submit results of test)
OR
15. Is the recipient receiving substance or alcohol abuse counseling services?
Yes
No
(Must submit supporting documentation)
By signing below, the prescriber attests that all statements provided are accurate.
Prescriber Signature: _____________________________________ Date: _______________________________________
Fax or mail completed forms to:
Magellan Medicaid Administration, Inc.
Prior Authorization
P. O. Box 7082
Tallahassee, FL 32314-7082
Phone: 877-553-7481
Fax: 800-424-5716
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