Form Dhmh 0514 - Hepatitis C Therapy Prior - Authorization Form

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Maryland Medicaid Pharmacy Program
1-800-492-5231-Option 3
Fax form to 410-333-5398
HEPATITIS C THERAPY PRIOR-AUTHORIZATION FORM
Incomplete form will be returned
Please attach copies of the patient medical history summary, lab and genetic test reports to the State.
**Please review our clinical criteria before submitting this form**
Patient Information
Recipient:______________________________________ MA#: _________________________________
Date of Birth:______/______/______ Body Weight:_______ kg
Phone #: (
) _______ - ________
□ Home
□ Hospital
□ Clinic
Patient location:
Diagnosis (Attach genotype test results)
□ Acute Hep C □ Chronic Hep C
□ Genotype of pre-transplant liver: __________________
□ Hepatocellular Carcinoma
□ Genotype of post-transplant liver: ____________________
other:__________________________________
What is patient’s HCV genotype (including subtype)?___________________________
Has a liver biopsy been performed?
Yes
No
Test date : _____/_______/________
Provide a copy of biopsy results or other fibrosis test, specify Metavir grade:_________________ stage:_________________
Hepatitis C Patient Characteristics
□ New Therapy
□ Relapser
□ Partial Responder
□ Non-Responder
This request is for:
□ Compensated cirrhosis (treatment naïve or experienced)
□ No cirrhosis
□ Decompensated liver d/s
Drug Regimen with Strengths/Dosages/Length of Therapy and Treatment Plan
Sovaldi®:____________________________________________ Olysio™:________________________________________
Pegylated interferon: _________________________________________ Ribavirin:____________________________________
Other: ____________________________________
Anticipated total treatment duration: _____________________________
(Adherence with prescribed therapy is a condition for payment for continuation therapy for up to the allowed timeframe
for each HCV genotype. The recipient’s Medicaid drug history will be reviewed prior to approval.)
Has drug therapy treatment plan been developed and discussed with patient
Yes
No
Any issues with drug adherence?
Yes Explain:_________________________________________________________
No
Adherence assessment:__________________________________________________________________________________
(DHMH 0514) Page 1 of 2

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