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