Claim number / Injured worker’s name
Pharmacy name / Telephone number / Fax number
Prescriber / Telephone number / Fax number
Drug/strength / Directions for use including treatment duration
Drug/strength / Directions for use including treatment duration
Drug/strength / Directions for use including treatment duration
1. What is the Hepatitis C genotype?
2. What is patient’s most recent HCV RNA viral load?
What date was this level determined?
3. Is patient treatment naïve? Yes No
4. Does patient have ascites? Yes No
If yes, what is the degree of ascites (slight or moderate)?
5. Does patient have encephalopathy? Yes No
If yes, what is the grade of encephalopathy?
6. Does patient have cirrhosis of the liver? Yes No
If yes, is liver: Decompensated Compensated
Is patient awaiting a liver transplant? Yes No
7. Does the patient have HCV-induced renal disease? Yes No
8. Does the patient have Type 2 or 3 essential mixed cryoglobulinemia with end organ manifestations? Yes No
9. Does patient have a co-infection with Hepatits B or HIV? Yes No
10. Has patient had a solid organ transplant? Yes No
If yes, which organ?
11. Does patient have stage I-III Hepatocelluar Carcinoma meeting Milan criteria? Yes No
12. Does patient have decompensated liver disease as defined by Child-Pugh-Turcottee classification score 7-12 (CPT Class B/C)
and MELD is <20? Yes No
13. Is patient currently (in last 6 months) abusing alcohol? Yes No
14. Is patient currently (in last 6 months) abusing IV drugs? Yes No
15. Does patient have any severe end organ disease? Yes No
If yes, are they eligible for a transplant? Yes No
16. Is the patient’s Creatinine Clearance <30ml/min or are they on hemodialysis? Yes No
17. Is client pregnant or planning on becoming pregnant? Yes No
18. Does patient have any comorbid condition that would prevent them from receiving long term clinical benefit from HCV
treatment? Yes No
19. Has patient attended a medical care visit with treating clinician to discuss the pros and cons of antiviral therapy, the importance
of adherence to treatment, and the risk factors for fibrosis progression? Yes No
20. Have you evaluated patient for psychosocial readiness for treatment and addressed any impediment to successful treatment?
Yes No
21. Is there another provider/specialist involved with this patient’s care for the same condition? Yes No
Include a copy of the results for at least one of the following:
FibroSURE
FibroScan
Liver biopsy
Abdominal imaging where radiologist determines findings are suggestive of cirrhosis
Provide recent lab results for ALL of the following:
Albumin
Total bilirubin
INR or PT
Platelets
AST
MELD (if applicable)
You must provide documentation, labs and chart notes to support information provided.
Prescriber signature / Prescriber specialty / Date
How to submit your request
State Fund
Fax completed form along with supportive medical documentation to 360-902-6315 ATTENTION: Drug Review Program.
Self-Insurance
Contact the self-insurer or their third-party administrator.