HEPATITIS C REFERRAL FORM

PATIENT INFORMATION: PHYSICIAN INFORMATION:

Patient Name: Physician Name:

Address: Address:

City: State: Zip: City: State: Zip:

Home Phone: Alternate Phone: Phone: Fax:

Email: Office Email:

Soc. Sec #: Weight: □kg □lbs Height: □ft □cm Key Office Contact

Date of Birth: Sex: □ Male □ Female BMI: State LIC # NPI # DEA#

Clinical Diagnosis: please fax or email relevant clinical notes, labs, tests and previous medical history to expedite prior authorization

Diagnosis / ICD-10: Cirrhosis: ☐ Compensated ☐ Decompensated ☐ None Viral Load (date): Genotype: Child-Pugh Class:

Fibrosis Score: ☐ Post liver transplant ☐ Hepatocellular arcinoma HIV Status: ☐ HBV Status: ☐ ☐ Patient is treatment naïve Prior Treatment (dates):

MEDICATIONS AND DIRECTIONS

Medication / Strength Recommended Dosing Guidelines Directions/ Quantity / Refills

□ Daklinza® (daclatasvir 60 mg and 30 mg tablets) Genotype 1 or 3, non-cirrhotic: DAC + SOF (12 weeks) □ Take 60 mg PO once daily

Genotype 1 or 3, cirrhotic: DAC + SOF +/- RBV (24 weeks) □ Other:

Genotype 2, non-cirrhotic, RBV ineligible: DAC + SOF (12 weeks)

Genotype 2, cirrhotic, RBV ineligible : DAC + SOF (16-24 weeks)

Genotype 1a: ns5a resistance testing is recommended Genotype 2, non-cirrhotic & cirrhotic, SOF + RBV experienced: DAC + SOF +/- RBV (24 weeks) QTY: REFILLS:

□ Epclusa® (sofosbuvir 400 mg / velpatasvir 100 mg) Genotypes 1-6, without cirrhosis and patients with compensated cirrhosis (Child-Pugh A): 12 weeks □Take 1 tablet PO once daily

Genotypes 1-6, patients with decompensated cirrhosis (Child-Pugh B and C): + RBV (12 weeks) With or without food

QTY: REFILLS:

□ Harvoni® (ledipasvir/sofosbuvir 90 mg / 400 mg tablets) Genotype 1, Treatment naïve, non-cirrhotic HCV RNA < 9 million IU: 8 weeks □Take 1 tablet PO once daily

* add RBV recommended when Tx experienced was SOF + RBV +/- IFN Genotype 1, Treatment naïve, non-cirrhotic & cirrhotic: 12 weeks □ Other:

** Genotype 4, Tx experienced, cirrhotic: with RBV for 12 weeks or *Genotype 1, Treatment experienced, non-cirrhotic: +/- RBV (12 weeks)

without RBV for 24 weeks *Genotype 1, Treatment experienced, cirrhotic: +/- RBV (12-24 weeks)

**Genotype 4, 5, 6, non-cirrhotic & cirrhotic: 12 weeks QTY: REFILLS:

□ Mavyret (glecaprevir 100mg / pibrentasvir 40mg) Genotype 1-6, Treatment-Naive, non-cirrhotic (8 weeks) □ Take 3 tablets PO once a day with foodGenotype 1-6, Treatment-Naive, compensated cirrhotic (12 weeks)

Genotype 1-6, NS3/4A PI-experienced (NS5A Niave), compensated cirrhotic/non-cirrhotic (12 weeks)

Genotype 1-6, NS5A-experienced (NS3/4A PI Naive), compensated cirrhotic/non-cirrhotic (16 weeks) QTY: REFILLS:

□ Olysio® (simeprevir 150 mg capsules) Genotype 1, non-cirrhotic: SIM + SOF (12 weeks) □Take 1 capsule PO once daily

Genotype 1, cirrhotic: SIM + SOF +/- RBV (Q80K-) (24 weeks) QTY: REFILLS:

□ Ribavirin 200 mg tablets □ Take________mg 9AM and __________mg 9PM QTY: REFILLS:

□ Sovaldi® (sofosbuvir 400 mg tablets) Genotype 1 or 3, non-cirrhotic: DAC + SOF (12 weeks) □Take 1 tablet PO once daily

Genotype 1 or 3, cirrhotic: DAC + SOF +/- RBV (24 weeks) □ Other:

Genotype 2, non-cirrhotic: SOF + RBV (12 weeks)

Genotype 2, non-cirrhotic, RBV ineligible: DAC + SOF (12 weeks)

Genotype 2, cirrhotic: SOF + RBV (16-24 weeks)

Genotype 2, cirrhotic: SOF + RBV + IFN (12 weeks)

Genotype 2, cirrhotic:, RBV ineligible: DAC + SOF (16-24 weeks)

Genotype 3, non-cirrhotic & cirrhotic, DAC + IFN ineligible): SOF + RBV (24 weeks)

Genotype 3, 4, 5 or 6, non-cirrhotic & cirrhotic: SOF + RBV + IFN (12 weeks) QTY: REFILLS:

□ Vosevi ™ (400mg sofosbuvir,100mg velpatasvir,and 100mg Voxilaprevir) tablets

Genotype 1,2,3,4,5 or 6 - Patients Previously Treated with an HCV regimen containing an NS5A inhibitor 12 weeks □ Take 1 tablet orally

once daily with food

QTY: REFILLS:

Genotype 1a or 3 - Patients Previously Treated with an HCV regimen containing sofosbuvir without an NS5A inhibitor 12 weeks

□ Zepatier™ Genotype 1a, without baseline polymorphisms: 12 weeks □ Take 1 tablet PO once daily

(elbasvir/grazoprevier 50 mg / 100 mg tablets) Genotype 1a, with NS5A polymorphisms: + RBV (16 weeks) □ Other:

Genotype 1b: 12 weeks

Genotype 1a or 1b, PI experienced: + RBV (12 weeks)

Genotype 4, Treatment naïve: 12 weeks

Genotype 4, Treatment experienced : + RBV (16 weeks) QTY: REFILLS:

□ Other

Prescriber Signature Required *Prescription is void if the number of drugs prescribed is not noted

I authorize Hawaii Specialty Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process.

PRESCRIBER SIGNATURE DATE NO. OF DRUGS PRESCRIBED ______ □ 1 □ 2 □ 3 □ 4 □ 5

x

Legal Notice: This fax transmission may contain confidential information belonging to the sender which is legally privileged. This information is intended only for the use of the recipient named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any action in reliance on the consents of this faxed information is strictly prohibited. Please notify us by phone to arrange for the return of the original documents. This prescription may be filled at a pharmacy of the patient's choice.

HAWAII SPECIALTY PHARMACY • 1150 S KING ST SUITE 1105 • HONOLULU, HI 96814 • PHONE: 833-767-5663 • FAX: 808-333-3682 • WWW.HISPRX.COM20170811v2

Please complete and attach to MDX priorAuthorization form