Oral oncology referral form

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.

Source: https://api.centene.com/providers/paforms/Ambetter_Hepatitis%20C%20PA%20Form_2013-12-26.pdf

Instruction manual

Collagenase NB 6 GMP Grade Cat. No. 17458 Protocol for isolation of human adipocytes (adult) Product Information General Collagenase NB 6 GMP Grade is designed for dissociation of human tissue for isolation of different cell types which are intended for transplantation in humans. The aseptical production process complies with the requirements of Annex 18 to the EU-Guide t

Atrophic vaginitis 5-17-06.pmd

A Systematic Review of Atrophic Vaginitis Treatment, Duration of Therapy, and Healthcare Costs Sanjeev Balu, PhD1; Ashish V. Joshi, MS, PhD2; David Cobden, MSc, MPH2; Won Chan Lee, PhD1; Chris L. Pashos, PhD1 1HERQuLES, Abt Associates Inc., Bethesda, MD, USA; 2Novo Nordisk Inc., Princeton, NJ, USA KEY FINDINGS Abstract Table 1: Duration of Hormonal Therapy • Studies have shown that A

© 2010-2018 Modern Medicine