Hepatitis C Treatment - Medical Necessity Request Form Page 3
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3Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
24. For each drug being requested, please indicate if member has any of the listed conditions or is taking any of the listed drugs.
Ribavirin
Viekira Pak, Technivie
Sovaldi
□ Pregnancy
□ Severe hepatic impairment (CTP Class C)
□ Men with pregnant female partner
□ Carbamazepine
□ Moderate hepatic impairment (CTP Class B)
□ Hemoglobinopathies (e.g., thalassemia
□ Phenytoin
□ Triazolam, midazolam given orally (Versed)
major, sickle-cell anemia)
□ Phenobarbital
□ Sildenafil if dosed as Revatio® for PAH treatment
□ Didanosine (Videx, Videx EC)
□ Oxcarbazepine
□ Carbamazepine, phenytoin, phenobarbital
□ Stavudine (Zerit, Zerit XR)
□ Rifabutin, rifampin, or rifapentine
□ Alfuzosin (Uroxatral)
□ Zidovudine (Retrovir, Combivir,
□ St. John’s Wort (Hypericum perforatum)
□ Voriconazole (Vfend)
Trizivir)
□ Tipranavir (Aptivus)
□ Rifampin
□ Autoimmune Hepatitis (Rebetol only)
□ Amiodarone when Sofosbuvir is used in
□ Ergotamine, dihydroergotamine, ergonovine,
□ Creatinine Clearance <50ml/min
combination with another direct acting
methylergonovine
(Rebetol only)
□ Efavirenz (Sustiva, Atripla)
antiviral
□ NONE
□ NONE
□ Darunavir (Prezista, Prezcobix) – for Viekira only
□ Lopinavir/ritonavir (Kaletra),
Olysio
□ Moderate or severe hepatic impairment
□ Rilpivirine (Edurant, Complera)
Harvoni
□ Carbamazepine
□ Gemfibrozil (Lopid) – for Viekira only
(CTP class B or C)
□ Phenytoin
□ Carbamazepine, phenobarbital,
□ Ethinyl estradiol (e.g., combined oral contraceptives)
□ Phenobarbital
□ Pimozide (Orap)
phenytoin, oxcarbazepine
□ Oxcarbazepine
□ Rifabutin, rifampin, rifapentine
□ St. John’s Wort (Hypericum perforatum)
□ Rifabutin, rifampin, or rifapentine
□ Erythromycin, clarithromycin,
□ Rosuvastatin (Crestor) >10mg/day- for Viekira only
□ St. John’s Wort (Hypericum perforatum)
□ Pravastatin (Pravachol) >40mg per day
telithromycin
□ Tipranavir (Aptivus)
□ Systemic dexamethasone
□ Lovastatin (Mevacor, Altoprev, Advicor)
□ Elvitegravir/cobicistat/emtricitabine/
□ Systemic itraconazole, ketoconazole,
□ Simvastatin (Zocor, Juvisync, Simcor, Vytorin)
□ Omeprazole >40mg per day
tenofovir (Stribild)
posaconazole, fluconazole, voriconazole
□ Tenofovir together with a HIV protease
□ Milk thistle, St. John’s Wort
□ Salmeterol (Serevent, Advair)
□ Known hypersensitivity to ritonavir (e.g. toxic
inhibitor/ritonavir in patients with CrCl
(Hypericum perforatum)
□ Efavirenz (Sustiva, Atripla)
< 60mL/min
epidermal necrolysis, Stevens-Johnson syndrome)
□ Rosuvastatin (Crestor)
□ Delavirdine (Rescriptor)
□ Ketoconazole > 200mg/day
□ H2-antagonists that exceed doses
□ Etravirine (Intelence)
□ Atazanavir, Atazanavir/ritonavir (Evotaz,
□ Nevirapine (Viramune, Viramune XR)
comparable to Famotidine >40mg twice
Reyataz)– for Technivie only
□ Darunavir (Prezista)
□ NONE
daily (i.e., Cimetidine >1600mg /day,
□ Ritonavir (Norvir)
Nizatidine >300mg/day, Ranitidine
Zepatier
□ any HIV protease inhibitor [e.g.,
□ Moderate or severe hepatic impairment (CTP Class
>600mg/day)
□ Proton Pump Inhibitors that exceed
Atazanavir (Reyataz, Evotaz),
B or C)
□ Atazanavir (e,g., Evotaz, Reyataz)
doses comparable to Omeprazole >20mg
Fosamprenavir (Lexiva), Lopinavir
□ Darunavir (e.g., Prezcobix, Prezista)
daily (i.e., Dexlansoprazole >60mg/day,
(Kaletra), Indinavir (Crixivan),
□ Lopinavir (e.g., Kaletra)
Lansoprazole >30mg/day, Pantoprazole
Nelfinavir (Viracept), Saquinavir,
□ Saquinavir (e.g., Fortovase, Invirase)
>40mg/day, Esomeprazole >40mg/day,
Tipranavir]
□ Cobicistat-containing products (e.g.,
□ Tipranavir (e.g., Aptivus)
Rabeprazole >20mg/day)
□ Amiodarone except in patients with no
□ Cyclosporine
Stribild, Evotaz, Prezcobix, Genvoya,
□ Carbamazepine, phenytoin
other viable alternative treatment options
Tybost)
□ Use with other drugs containing
□ Cyclosporine
□ Rifampin
□ Rosuvasatin >10mg/day
□ St. John’s Wort (Hypericum perforatum)
sofosbuvir
□ NONE
□ Atorvastatin >40mg/day
□ Efavirenz (e.g., Atripla, Sustiva)
□ NONE
□ Nafcillin
□ Bosentan
Daklinza
□ Etravirine
Pegasys, Peg-Intron, Intron-A
□ Amiodarone
□ Modafinil
□ Dabigatran (Pradaxa) if CrCl <50ml/min
□ Cobicistat (Stribild, Evotaz, Prexcobix, Genvoya,
□ Autoimmune Hepatitis
□ Phenytoin, carbamazepine
Tybost)
□ Hepatic decompensation or
□ Rifampin
□ Ketoconazole
decompensated liver disease
□ St. John’s wort (Hypericum perforatum)
□ Atorvastatin >20mg/day
□ NONE
□ NONE
□ Rosuvastatin >10mg/day
□ NONE
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
3 of 3
Rev. 3/16
HNJH Fax #: 888-567-0681
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