Form Dhmh 0514 - Hepatitis C Therapy Prior - Authorization Form Page 2
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2Laboratory Results
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Has a test been performed for the Q80K polymorphism?
Yes
No
Test date: _______/_______/________
Baseline HCV RNA level (within 30 day pre-treatment): _____________ log10______
Date:_______/________/_______
HCV RNA Level at Treatment week 4 : ______________ log10_______ Date measured:_______/________/_______
at Treatment week 12 :_______________ log10_______ Date measured: _______/_______/________
at Treatment week 24 :_______________ log10_______ Date measured: _______/_______/________
Date of HCV RNA rebound (≥ 1 log10 increase from the nadir HCV RNA) any time while on treatment: _____/______/______
Liver enzyme levels: Baseline ALT/AST:______________________________ Date measured:________/_______/______
Baseline platelet:________________________________ Date measured:________/_______/______
Baseline hemoglobin/hematocrit:_____________________________________ Date measured:________/_______/______
Medical History
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Does patient have HIV/HCV co-infection?
Yes
No
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Has patient had a solid organ transplant?
Yes
No Specify transplant date:________/_________/_________
Does the patient have a history of any of the following:
□ anemia
□ autoimmune hepatitis or other autoimmune conditions
□ pregnant
□ renal d/s
□ thrombocytopenia
□ severe concurrent medical d/s (i.e. AIDS, cancer, significant CAD)
□ hemoglobinopathies (i.e. sickle cell, thalassemia)
□ currently on didanosine □ unstable CVD
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Does patient have history of depression or mood disorder?
Yes
No
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If yes, is patient stable on current medication?
Yes
No
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Does patient have history of Drug/Alcohol Abuse?
Yes
No If yes, is patient abstinent for last 6 months?
Yes
No
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If no, is patient currently in drug rehabilitation program?
Yes
No
Prior Drug Utilization
List concomitant drugs that might interact with any of the prescribed Hep C drugs:__________________________________
____________________________________________________________________________________________________
List all previous hepatitis C therapies including adverse effects associated with prior therapy and reason for drug failure. If the
patient is contraindicated or ineligible to receive a portion of a therapy (interferon), please provide a reason:______________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If patient’s Medicaid eligibility change during therapy and patient is no longer eligible for Medicaid prescription drug assistance, is
the physician prepared to enroll the patient in other patient assistant drug programs to complete therapy?
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YES
NO
I certify that the information provided is accurate. Supporting documentation is available for State audits.
Prescriber’s Name: _________________________________ Date: _____/____ /____
_______________________________
(Prescriber’s signature)
Practice Specialty: _________________________________________________________________________________________
Telephone# (______) – ____________- ___________
Fax# (_______) - ____________ - ___________
Address: _________________________________________________________________________________________________
(DHMH 0514) Page 2 of 2
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