HCV Medication Therapy Information and Request Sheet, v 0 1 2 3 1 5
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Arkansas Medicaid Prescription Drug Program
Hepatitis C Virus (HCV) Medication Therapy Information and Request Sheet
After completing the request form please fax to the Arkansas Medicaid Pharmacy Program. Fax: 1-800-424-5851
For questions call: 501-683-4120.
All supporting documentation must accompany this form .
PART 1: TO BE COMPLETED BY PHYSICIAN
PHYSICIAN
AR MEDICAID ID NUMBER:
RECIPIENT
MEDICAID ID NUMBER:
Physician Name:
Patient Name:
Address:
Address:
City:
State:
Phone (
Zip:
City:
State:
Patient’s date of birth:
)
/
Zip:
/
FAX
(
)
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.
Arkansas Medicaid is monitoring the evolving therapeutic options for Hepatitis C. Given the regular reporting of new results of several novel
agents alone and in combination, the absence of long term clinical outcomes data, and the imminent approval of additional medications,
Arkansas Medicaid has adopted a conservative approach to HCV therapy at this time to be revised as new information becomes available.
Many factors will be reviewed and prescribers may be asked to provide the medical necessity of urgency for treatment.
Please indicate which medications are being requested and complete the information below:
Ribavirin capsules
Ribavirin tablets
(only the generic 200mg ribavirin tablets/capsules will be approved)
Pegasys® _________________ (strength)
PegIntron® ________________ (strength)
Sovaldi®
Olysio®
Viekira Pak®
Harvoni® (at this time, Harvoni will be approved for only 8 week course based on package insert)
*****************************************************************************************************************************************************************************
Section One – Initial PAs
1. Indicate reason for request:
Acute Hepatitis C
2. This request is for TREATMENT NAÏVE
Chronic Hepatitis C
TREATMENT EXPERIENCED
Other
Define other: ______________
CONTINUATION REQUEST
3. What is patient’s HCV genotype?___________________________ (Genotype 1a
1b
2
3
4
5
6)
4. What is patient’s baseline quantitative HCV RNA viral load test results: _____________________ date measured:_________
5. Does patient have HIV/HCV co-infection? YES
NO
If Yes, please note that when possible, patients receiving zidovudine (AZT) and especially didanosine (ddI) HIV medications
should be switched to an equivalent antiretroviral agent before beginning therapy with ribavirin. HIV-infected patients with
decompensated liver disease (CTP Class B or C) should not be treated with peginterferon alfa and ribavirin for HCV. 1
1
Ghany, et al, (2009, April). American Association for the Study of Liver Diseases (AASLD) Guidelines. Diagnosis, Management, and Treatment of Hepatitis C: An
Update. Treatement of Persons with HIV Coinfection. Hepatology, 49(4),1353.
HCV Medication Therapy Information and Request Sheet, v 0 1 2 3 1 5
6. What are the patient’s liver enzyme levels?
ALT/AST _____________
7. Does the patient have a diagnosis of cirrhosis?
YES
8. Has a liver biopsy been performed?
NO
Stage: 0
1
2
3
4
Grade: 1
YES
2
3
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Date measured: ________________
(LIVER BIOPSY REQUIRED)
NO
Please include copy of biopsy results.
4 (circle one) **This information is mandatory for ALL requests**
9. Does the patient have any extrahepatic disease manifestations caused by HCV? YES
NO
If Yes, list: ________________________________________; Supporting documentation must be included with PA request.
10. Does the patient have a history of any of the following? Please mark all that apply.
Anemia
Thrombocytopenia
Untreated hyperthyroidism
Unstable CVD
Autoimmune disease
Chronic Kidney Disease (Stage 3 – Stage 5D)
Kidney transplant
Depression, irritability, suicidal ideation
Pregnancy (ribavirin causes significant teratogenic effects for as long as 6 months after completion of therapy2)
Other mental illnesses, including bipolar disorder, mood swings, mania, or schizophrenia
11. If applicable, has the patient been abstinent from IV drug use or alcohol abuse for > 6 months?
YES
NO
If NO, is patient currently enrolled in drug rehabilitation program?
YES
NO
Section Two – Continuation PAs (Please fax the lab results to 501-683-4124)
4 week HCV RNA viral load: __________________________
8 week HCV RNA viral load: __________________________
12 week HCV RNA viral load: __________________________
24 week HCV RNA viral load: __________________________
12. If patient’s Medicaid eligibility changes 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?
YES
NO
The above format is to assist the physician in providing medical documentation that Arkansas Medicaid requires to review this
request. Please provide copies of supporting lab documentation for above request.
Physician Signature: ______________________________________________
2
Date: _____________________
Black box warning. Ribavirin causes significant teratrogenic effects. Copegus® (ribavirn) package insert. Roche Laboratories, Inc. Revised April 2009. Retrieved May 20,
2009, from http://www.rocheusa.com/products/copegus/pi.pdf.