Dolphin’s Hepatitis C Checklist

© 2020. Dolphin Health Specialty Pharmacy. All rights reserved.

Please make sure you send all of the following in one fax if possible. This will help expedite our eligibility and prior authorization process.

What is attached?

❑ Demographics

❑ Last 2 Visit Notes

❑ Fibrosis documentation (biopsy, fibroscan, fibrosure)

❑ HCV Genotype

❑ HBV (*if available)

Last 90 days:

❑ HCV RNA Viral Load (last 90 days)❑ CBC w/ PLT (last 90 days)❑ Complete Metabolic Panel (last 90 days)

❑ Imaging (*if available)

❑ PT/INR (*if cirrhotic)

❑ NS5A Resistance Testing for GT1A and GT3

❑ Current Medications

❑ Patient Adherence / readiness documentation

Special Comments or Requests

www.dolphinhealth.com

Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605

Page 1 of 3

PLEASE ATTACH FRONT AND BACK OF THE PATIENT’S INSURANCE CARD

FRONT

BACK

Sender

ATTN:

Hepatitis C Form

© 2020. Dolphin Health Specialty Pharmacy. All rights reserved Updated 4/23/2020. Page 2 of 3

www.dolphinhealth.com

Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605

1

Provider InfoName Contact

NPI DEA LIC

Address City State, Zip

Phone Extension Fax

Coordination

Today Need By RX Type ❑ New ❑ Refill

Ship To ❑ All fills to Patient ❑ 1st fill to Clinic ❑ All fills to Clinic q Other Training By ❑ Dolphin ❑ Clinic ❑ N/a

Insurance ❑ Commercial ❑ Medicare ❑ Medicaid ❑ Cash Patient Impaired ❑ Hearing ❑ Vision

Patient Info

Name DOB SSN

Address City State, Zip

Phone Caretaker Language

Email Height ❑ In ❑ cm Weight ❑ lb ❑ kg

Tried & Failed

Medication Start Date End Date Reason for Discontinuation

Non-Adherence Concerns?

Hepatitis C Form

Clinical

Diagnosis q B18.2 Chronic Hepatitis C Diagnosis Date:

Genotype: q 1a q 1b q 2 q 3 q 4 q 5 q 6 Cirrhosis q None q Compensated q Decompensated

Fibrosis: q F0 q F1 q F2 q F3 q F4 Baseline Viral Load: _______ IU/mL

Baseline Viral Load Date: Co-Infection q HBV q HIV q N/a

Polymorphism: q NS5A q IL28B q Q80K q N/a Treatment Naive q Yes q No

Hepatitis B Screening q Yes q No Ethnicity:

Allergies Concurrent Medications:

Comorbidities:

q Type 2 DMq Debilitating Fatigueq HIV

Elevated Risk of Transmission

q Women; child bearing, wishing to get pregnantq HCV infected healthcare worker, performs exposed prone proceduresq MSM w/ high risk sexual practicesq Long-term HD

Extrahepatic Manifestations

q Porphyria Cutanea Cardaq HCV-related kidney Diseaseq Symptomatic Cryoglobulinemia

Date:

© 2020. Dolphin Health Specialty Pharmacy. All rights reserved Updated 4/23/2020.

www.dolphinhealth.com

Page 3 of 3

Signature

By signing below, the prescriber gives consent to both, the prescription(s) above, as well as to Dolphin Health to act as the prescriber’s agent to begin and to execute the prior authorization process and to help the patient apply to co-pay assistance programs, including all foundations and manufacturer programs if necessary.

Provider Date q Do Not Substitute

Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605

Verify

Patient DOB Provider Date

Hepatitis C Form

Prescription

Medication Strength Directions Duration QTY REFILLS

❑ Epclusa ® ❑ 400/100mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 24 28

❑ Harvoni ® ❑ 400/90mg ❑ Take 1 tablet by mouth ONCE daily.q 8q 12q 24

28

❑ Mavyret ® ❑ 100/40mg ❑ Take 3 tablets by mouth ONCE daily.q 8q 12q 16

84

❑ Sovaldi ® ❑ 400mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 24 28

❑ Vosevi ® ❑ 400/100/100mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 24 28

❑ Zepatier ❑ 50/100mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 16 28

❑ Ribapak❑ DAW1

❑ 600 mg❑ 800 mg❑ 1,000 mg❑ 1,200 mg

❑ Take ________ mg QAM, _______mg QPM, with food q 12q 24

❑ Ribasphere

Tablets

❑ 200mg❑ 400mg❑ 600mg

❑ Take ________ mg QAM, _______mg QPM, with food q 12q 24