Hepatitis C Treatment - Medical Necessity Request Form
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3Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Hepatitis C Treatment – Medical Necessity Request
1. Which drugs are being requested (please include the requested dose, directions and length of therapy for each)?
□ Pegasys: ________________
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ PegIntron: _______________
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Ribavirin: ________________
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Sovaldi 400mg once daily
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Olysio 150mg once daily
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Harvoni 90-400mg once daily
□ 8 weeks
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Viekira Pak
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Daklinza 60mg once daily
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Technivie
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Zepatier 50-100mg once daily
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
□ Other: ___________________
□ 12 weeks
□24 weeks
□ 16 weeks
□ Other: ____________
2. What is the member’s weight? _____lbs ____kg
3. What is the member’s height?_____feet _____ inches
4. What is the diagnosis? □ Hepatitis C - Please indicate genotype: □1a □ 1b □ 2 □ 3 □ 4 □ 5 □ 6
□ Other: _______________
*Please submit lab documentation of genotype.
5. What date did the member start or is planning to start therapy? _____________
6. Has the member previously been treated for Hepatitis C? Yes or No
-
If yes, what drugs was the member treated with and what dates were they filled (if dates unavailable, provide length of therapy)?
___________________________________________________________________________________________
Please indicate member’s treatment response:
-
□ Null-responder
□ Relapser
□ Partial Responder
□ Other (please specify):___________________
-
Please provide the HCV RNA levels in IU/mL from previous therapy: ___________________________
-
Is the member currently in the middle of therapy? Yes or No - If yes, how many weeks has the member received? ___________
7. Does member have cirrhosis? □ No cirrhosis
□ Compensated cirrhosis
□ Decompensated cirrhosis
- What is the Child Turcotte Pugh (CTP) class: □ A (5-6 points) □ B (7-9 points) □ C (10-15 points)
8. Please provide the following scores regarding the member’s level of fibrosis. *Please fax over biopsy/lab documentation.
□ 0 (No fibrosis)
□ 1
□ 2
□ 3
□ 4
Metavir fibrosis score:
Fibroscan score: _____________
FibroSURE score: ___________
APRI score: ________________
FIB-4 (Fibrosis-4 index): ______________
9. Is the member HIV-positive? Yes or No
*If yes, please submit lab documentation
Is the member currently taking Antiretroviral therapy? Yes or No
10. Has the member received an organ transplant? Yes or No *If yes, date of transplant____________ Which organ? _____________________
(If yes, please submit documentation)
11. Does the member have any of the following conditions? (If yes, please submit documentation)
a. Nephrotic Syndrome: Yes or No
b. Membranoproliferative glomerulonephritis: Yes or No
c. Type 2 or 3 essential mixed cryoglobulinemia with end-organ manifestations (e.g., vasculitis): Yes or No
d. Proteinuria Yes or No *If yes, please list and fax over all lab results for member’s Albumin-to-Creatinine Ratio (ACR) taken within
the past 90 days
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
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Rev. 3/16
HNJH Fax #: 888-567-0681
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