Passport Health Plan Prior Authorization Hepatitis C Therapy

Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and subject to all privacy and security regulations under HIPAA

Page 1 of 4

Fax or mail completed forms to: Magellan Pharmacy Solutions 11013 West Broad Street, Suite 500 Glen Allen, VA 23060

Phone: 1-800-846-7971 Fax: 1-800-229-3928

Patient Last Name: Patient First Name:

Member ID Number: Date of Birth (MM/DD/YY):

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Address Apt # or Suite #

City State Zip Code

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Phone Number Weight

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lbs

kgs

Physician’s Name License #

Address Apt # or Suite #

City State Zip Code

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Contact Person

Contact Person Phone Number Contact Person Fax Number

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LTC Member: Yes No Date Admitted: ___________________

PASSPORT’S PREFERRED SPECIALTY PHARMACY ICORE DELIVER TO: Physician’s Office Patient’s Home OR Patient Filling at local Pharmacy LOCAL PHARMACY NAME (IF AVAILABLE):______________________________________PHONE:______________________

What is/are the requested medications? Harvoni for weeks Sovaldi/Ribavirin* for weeks Sovaldi/Ribavirin*/Peginterferon alfa** for weeks Sovaldi/Olysio for weeks Other: weeks Viekira Pak for weeks

*Ribavirin 200 mg indicate sig: ___________________________________________________________________________ **Peginterferon alfa: Peg-Intron (Dose and Sig: __________________________) Pegasys 180 mcg weekly

(If requesting a medication other than Peg-Intron, please provide documentation of a medical reason for why the patient is unable to take Peg-Intron to treat his or her medical condition and attach any necessary documentation.)

FORM MUST BE COMPLETED IN FULL. PLEASE PROVIDE ALL OF THE REQUESTED INFORMATION AND SUPPORTING CLINICAL DOCUMENTATION. NEW START

Treatment Start Date: _________________________________ Date of 4 week labs to be done: _________________________________ Initial length of authorization is 8 weeks. Follow up viral titers are required at 4 weeks to determine medical necessity of continuing treatment.

CONTINUATION OF ONGOING THERAPY Provide follow-up HCV Viral Load as appropriate for intended duration of therapy: Week 4 Result: ___________________ Date: ______________ Week 12 Result: ___________________ Date: ______________ Week 20 Result: ___________________ Date: ______________

1.

Supporting lab work (please attach to request) required for the following: Chronic HCV infection: Yes No Genotype? 1a 1b 2 3 4 Other:_________ If type 1a, NS3 Q80K polymorphism No Yes Most recent HCV Viral Load: ___________ IU/ml __________ or Copies/ml Lab Date: _______________

2. HIV Co-infected: Yes No If YES, CD4 Count: ____________ Lab Date: __________ RNA Viral Load: ____________ Lab Date: _______________

Passport Health Plan Prior Authorization Hepatitis C Therapy

Note: Form must be completed in full. An incomplete form may be returned. Information on this form is protected health information and subject to all privacy and security regulations under HIPAA

Page 2 of 4

Fax or mail completed forms to: Magellan Pharmacy Solutions 11013 West Broad Street, Suite 500 Glen Allen, VA 23060

Phone: 1-800-846-7971 Fax: 1-800-229-3928

Patient Last Name: Patient First Name:

3. Hepatitis B co-infected: Yes No If YES, HBV Viral Load: ________ IU/ml __________ or Copies/ml Lab Date: ________________

4. Is the member at least 18 years old? Yes No

5. Have the member and prescriber together reviewed, completed, signed, and attached the PHP Member Disclosure & Commitment Form? Yes No

6. Liver transplantation? Not indicated Awaiting liver transplant (Date: ____________) Post-transplant

7.

Has the member been previously treated with HCV therapy? No Yes If yes, please specify regimen and duration: _______________________________________________________________________________ Did member complete previous treatment? Yes No (If no, please provide documentation why therapy was discontinued or not completed: ____________________________________________)

8. Is member currently receiving therapy with any of the following (check all that apply):

Sovaldi Olysio Harvoni Peginterferon alfa Ribavirin Victrelis

9.

Does member have chronic HCV with cirrhosis? Yes No METAVIR Score: ______________ If cirrhosis, what type? Compensated Decompensated Does the member have hepatocellular carcinoma? Yes No Please provide documentation (attached to request) of liver biopsy result OR at least 2 of the following:

Liver biopsy result: _______________________________________________________________________Date: ___________ Ultrasound based transient elastography score: ________________________________________________Date: ___________ Fibrotest score: __________________________________________________________________________Date: ___________ Cirrhotic features on imaging Ascites Esophageal varices Physical exam consistent with cirrhosis APRI Score (provide supporting lab results below and attach): ___________________________________________________ FIB-4 Score (provide supporting lab results below and attach): ___________________________________________________

Aspartate Aminotransferase (AST): ____________ Normal range: ___________ Lab Date: ___________ Alanine Aminotransferase (ALT): ______________ Normal range: ___________ Lab Date: ___________ Platelet Count: ____________________________________________________ Lab Date: ___________

10.

Member has been evaluated for current history of substance abuse and alcohol: Yes No Screening tool used: AUDIT C CAGE NIDA drug screening tool Other: ___________________________ Does member have history of substance or alcohol abuse within past 6 months? Yes No If history within past 6 months, member has completed/is participating in:

Recovery Program Counseling Services Seeing addiction specialist. Name of program/service/specialist: _________________________________________________ Is member committed to continuing to abstain from use of alcohol and illicit drugs during HCV treatment? Yes No Urine/laboratory toxicology screen results (attach with request): _____________________________________________________

11.

Member has evidence of the following (check all that apply; documentation required, attach with request): Evidence of essential mixed cryoglobulinemia with end organ manifestations Evidence of Nephrotic Syndrome Evidence of membranoproliferative glomerulonephritis Severe renal impairment or ESRD Evidence of proteinuria

For continuation of therapy beyond week 8, HCV RNA titer from treatment week 4 must be submitted and prescriber must again attest to substance abuse criteria (see box #10) for renewal of therapy. If indicated for treatment duration beyond 12 weeks, HCV RNA titers must be submitted every 8 weeks for continuation of treatment.

PHYSICIAN’S SIGNATURE: DATE: PHYSICIAN’S SPECIALTY:

Member Treatment Agreement – Hepatitis C Medicine

I, _____________________, have talked to my provider about taking Hepatitis C

medicine. I understand and agree to the following:

• Iwilltake__________________startingon____________.Iwilltakethismedicine

______________________________for________________________.

• IfIdonottreatHepatitisC,itcouldgetworseandIcoulddevelopcirrhosis,livercancerorliverfailure.

• Therearerisksandpossiblesideeffectslinkedtotakingthismedicine.Ihavetalkedtomyproviderabouttherisksandbenefits.Iagreetofollowthetherapyasinstructedbymyprovider.

• I’vehadthechancetoaskquestionsaboutHepatitisC,othertreatmentoptionsandtheriskoftreatment.Ihaveenoughinformationtounderstandmytreatment.

• TherearenopromisesthatthismedicinewillcureHepatitisC.• IhavebeengivenacopyofthisAgreement.

To help make my treatment a success, I agree to:• Takemymedicineasorderedunlessmydoctorstopsthemedicine.• Gotoallofmyfollow-upvisits.• Takeanylabtestsmydoctororderstoseeifthemedicineisworking.• Takeanyalcoholordrugtestsmydoctororders.IknowthattakingalcoholanddrugscouldmakemytreatmentlesseffectiveandmakemyHepatitisCworse.

• Receivemedicinecounseling,educationandtraining.

By signing here, I agree to ALL of the bullet points on this page.

Signature:_________________________________________

Date:_____________________________________________

Prescriber’sSignature:______________________________

Date:_____________________________________________

nameofmedicine

weekswhen/how

PROV-40838APP_12/30/2014

date

Member’sname

Permission to Contact

I_____________________________,givePassportHealthPlanpermissiontocontact

mebyphone.IunderstandthatPassportmaycallmetotalkaboutmyHepatitisC

treatmentandtrytohelpmegetthemostoutofmytherapy.

Signature: _________________________________________

PhoneNumber: ____________________________________

Date:______________________________________________

PROV-40838APP_12/30/2014

Member’sname