Hepatitis C Treatment - Medical Necessity Request Form Page 2
ADVERTISEMENT
1
2
3Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
12. Does the member have hepatocellular carcinoma?
□Yes – Please answer the following:
- Is the member awaiting liver transplantation? Yes or No
- What date is the liver transplant scheduled for: __________
□ No
13. Which specialist is prescribing the medication(s): □ Gastroenterology, □ Infectious Disease, □ Hepatology, □ Liver Transplant,
□ Other: __________
14. Does the member have severe renal impairment?
□Yes *Please submit lab documentation from within the past 30 days
- Is the urgency to treat high? Yes or No
- Is renal transplant an immediate option? Yes or No
□ No
15. What is the member’s Creatinine Clearance (CrCl) ____________ (ml/min)?
What is the member’s Serum Creatinine (SCr) __________ (mg/dl)?
16. Does the member have End Stage Renal Disease? Yes or No
*Please submit documentation from within the past 30 days
17. Is member using illicit intravenous/intranasal substances and/or abusing alcohol? Yes or No
- If yes, is the member receiving substance abuse counseling? Yes or No
18. Please provide the current HCV RNA level taken within the past 90 days and date taken.
*Please fax over lab report confirming this level.
- Level: _____________IU/ml
Date Taken: ______________
19. Is the member eligible to receive interferon?
□ Yes
□ No – Please provide the specific reason why the member cannot take interferon. Please submit a copy of lab work from within the past
30 days if applicable for the reason provided.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
20. Is the member eligible to receive ribavirin?
□ Yes
□ No – Please provide the specific reason why the member cannot take ribavirin. Please submit a copy of lab work from within the past
30 days if applicable for the reason provided.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
21. For Olysio requests only: Does the member have NS3 Q80K polymorphism? Yes or No
*Please fax over lab documentation.
22. For Zepatier requests only: Does the member have a detectable baseline high fold-change NS5A RAVs for elbasvir? Yes or No
*Please fax over lab documentation.
23. Please fax over any additional labs or clinical information pertaining to the member’s diagnosis.
Continued on p. 3
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
2 of 3
Rev. 3/16
HNJH Fax #: 888-567-0681
Page
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical