Send To: AcariaHealth
Specialty Pharmacy Provider:________________
Date: ___________ Date Medication Required:____________
Ship to: Physician Patient’s Home Other __________
Prior Authorization Form Hepatitis C
Patient Name: ___________________________________________________ Physician Name: _______________________________________________ Address: _______________________________________________________ State Lic #______________________ DEA # ________________________ City: ________________________________State: _______Zip:____________ NPI # _________________________ Specialty: _____________________ Home Phone: (___________) ___________ - _________________________
Practice Name/Hospital: _________________________________________
Work Phone: (_______) _____________ - _________________________
Address: _____________________________________________________
Cell Phone: (__________) _____________ - _________________________ City: __________________________ State: ________ Zip: ____________ Patient Soc. Sec #: _________________ Al ergies:_______________________ Physician’s Ph: (__________) ____________ - ______________________ Date of Birth: ___/___/___ Sex: Male Female Weight _____ lbs kg Physician’s Fax: (__________) ____________ - _____________________ Height: _______ BSA: ________ m² See attached demographic sheet Nurse/Key Of ice Contact: ________________________________________
IN SURANCE INFORMATION (Complete or At ach Copies of cards) DIAGNOSIS (Required)
Acute Hepatitis C Chronic Hepatitis B Essential thrombocythemia Chronic Hepatitis D
Hepatitis C after liver transplantation Chronic Hepatitis C Other: __________________________________
What is the ICD9 / ICD10 code? ________________________ PATIENT EVALUATION Centene Health Plans uses Victrelis as their preferred Protease Inhibitor product. If patient is not able to take Victrelis, please provide additional documentation with the clinical indication as to why patient cannot take Victrelis. Drug: ______________ Dose: ______________ Frequency: ____________ Drug: ______________ Dose: ______________ Frequency: ____________ Drug: ______________ Dose: ______________ Frequency: ____________ 2. If the patient is currently on therapy, what drug(s) is the patient currently on?
New Start (Patient is not cur ently on treatment)
Drug: ______________ Dose: ______________ Frequency: ____________
Drug: ______________ Dose: ______________ Frequency: ____________
Drug: ______________ Dose: ______________ Frequency: ____________
3. Check which, if any, of the following apply to the patient. Fax supporting documentation If none apply, mark “None of the above”:
Uncontrolled major depression or severe mental il ness
Unwil ing to use adequate contraception (self or partner)
Poorly controlled or deteriorating cardiac disease
4. Does the patient have documented sobriety from alcohol and/or il icit IV drugs for atleast 6 months prior to start of therapy? Yes No
Creatinine Clearance ________________ mL/min If creatinine clearance is unavailable, provide the fol owing:
Serum Creatinine ________________ mg/dL AND Weight ________________ lbs / kg (circle one)
6. If the creatinine clearance is less than 50 mL/min, wil the patient be treated with reduced doses of both ribavirin and IFN with careful monitoring by a specialist?
7. Is the infection confirmed by the presence of HCV RNA in the serum? Yes No
Continued on the next page… Phone: (800) 511-5144 Fax: (855) 521-1728
Patient Name:__________________________
8. Document baseline viral load: ________________ IU/ml Fax copy of results
9. What is the Hepatitis C Virus (HCV) genotype? ________________ Fax copy of results
Retreatment due to prior nonresponse
11. Is this the first time the patient has ever been retreated? Yes No
12. Has the patient had a prior therapy with PEG-IFN monotherapy? Yes \ No
13. If Victrelis or Incivek is not being prescribed, are both Victrelis AND Incivek contraindicated? Yes No Victrelis/Incivek are being prescribed
14. Is the patient co-infected with HIV? Yes No If No, skip to next section
15. Document CD4 Count: ________________ cells/mm3
16. Is the patient cur ently receiving or wil be receiving Videx (didanosine)? Yes No
Complete questions 17 - 28 if Incivek or Victrelis are being prescribed. If not prescribed, skip to #30 Centene Health Plans uses Victrelis as their preferred Protease Inhibitor product. If patient is not able to take Victrelis, please provide additional documentation with the clinical indication as to why patient cannot take Victrelis. 17. Has patient previously failed therapy with a treatment regimen that includes a protease inhibitor (e.g., Incivek, Victrelis)? Yes No
18. Does patient have cir hosis? Yes No
19. Which medication is being prescribed? Incivek Victrelis If Victrelis, Skip to #25
20. Does the patient have an intolerance or contraindication to Victrelis? Yes No
21. Wil Incivek be given in combination with a drug that is highly dependent on CYP3A for clearance or strongly induce CYP3A? Yes No If Yes, Indicate below
22. Has patient received Incivek as part of the current treatment course? Yes No
23. Wil HCV RNA levels be assessed at weeks 4, 12, and 24 of treatment? Yes No
24. Wil Victrelis be given in combination with a drug that is highly dependent on CYP3A4/5 for clearance or potent CYP3A4/5 inducer? Yes No
Tegretol (carbamazepine) Zocor (simvastatin)
Ergot derivatives [ie, Migranal (dihydroergo- Orap (pimozide)
tamine), ergonovine, Cafergot (ergotamine),
25. Has patient received Victrelis as part of the current treatment course? Yes No
26. Wil HCV RNA levels be assessed at weeks 4, 8, 12, and 24 of treatment? Yes No
Continued on the next page… Phone: (800) 511-5144 Fax: (855) 521-1728
Patient Name:__________________________
27. Wil patient receive 4 weeks of PEG-IFN and ribavirin prior to starting Victrelis? Yes No
28. Is the patient cur ently on the prescribed therapy? Yes No If No, No further questions Only answer below questions if patient is currently receiving therapy.
29. What date did patient start treatment? ________________ (MM/DD/YY)
30. Was the patient poorly interferon responsive (i.e., <1.0-log10 HCV-RNA decline in viral load) at week 4 of treatment? Yes No
31. If patient did not have greater than or equal to 2 log decrease, was there an interruption in therapy? Yes No
32. With prior therapy, did the patient have less than a 2-log10 drop in HCV-RNA after 12 weeks of treatment (i.e., null responder)?
Yes No First course of treatment
Document patient’s HCV-RNA levels (in IU/mL) for ALL completed weeks of therapy and include date drawn. If viral load is undetectable at the specified week, check “undetectable viral load.”
33. Week 4 of treatment HCV-RNA level: ___________________ IU/mL Undetectable viral load
Date (to be) Completed: ___________________
34. Week 8 of treatment HCV-RNA level: ___________________ IU/mL Undetectable viral load
Date (to be) Completed: ___________________
35. Week 12 of treatment HCV-RNA level: ___________________ IU/mL Undetectable viral load
Date (to be) Completed: ___________________
36. Week 24 of treatment HCV-RNA level: ___________________ IU/mL Undetectable viral load
Date (to be) Completed: ___________________
Please fax all labs and progress notes with this request. We can NOT make a decision without a copy of the documentation MEDICATION STRENGTH DIRECTIONS QUANTITY Physician’s Signature: ____________________________________ DAW (Dispense as Writ en) Date____/_____/____ IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.
DRUG EDUCATION I. INTRODUCTION TO DRUG TERMS 1. Any chemical substance that can alter the mind or body. B. Drug Use 1. When a drug is used properly for its intended purpose. C. Drug Misuse 1. Occasional use of a drug beyond its intended purpose. D. Drug Abuse 1. The repeated use of a drug beyond its intended purpose. E. Medicines 1. Any drug used to treat an illness or injury
J. Phys. Chem. B 2004, 108, 17992-18002 Computational Study of γ -Butyrolactone and Li + / γ -butyrolactone in Gas and Liquid Phases Marco Masia* and Rossend Rey Departament de Fı ´ sica i Enginyeria Nuclear, Uni V ersitat Polite ´ cnica de Catalunya,Campus Nord B4-B5, Barcelona 08034, Spain Recei V ed: July 8, 2004; In Final Form: September 8, 2004 A comprehensive stu
Send To: AcariaHealth 
Phone: (800) 511-5144 
Phone: (800) 511-5144