READINESS Please indicate which of the following scales/assessment tools was used to evaluate the readiness of the patient (only one is required): SAMHSA-HRSA & – – SAMSHA-HRSA C (PREP-C) – CONTINUATION THERAPY REQUESTS **This portion is not required for initial therapy requests 4 (±2 HCV RNA 12 HCV RNA Has documentation confirming HCV RNA levels at the appropriate week been submitted? Yes No Has the patient completed all HCV evaluation appointments and procedures and demonstrated compliance to their treatment regimen? Yes No CURRENT TREATMENT REGIMEN Please indicate the Sovaldi combination treatment regimen that is being prescribed: *For patients with HCV/HIV-1 co-infection, follow the dosage recommendations ^Recommended treatment regimen and duration for pediatric patients who are 12 years of age or weigh 35kg. ≥ ≥ **Consider screening for the presence of NS5A polymorphisms at amino acid positions M28, Q30, L31, and Y93 in patients with cirrhosis who are infected with HCV genotype 1a prior to the initiation of treatment with Daklinza and Sovaldi with or without RBV. ¥Consider screening for the presence of NS 3Q80K polymorphism in patients who are infected with HCV genotype 1a prior to initiation of treatment with Olysio and Sovaldi. Please provide dosing information for the treatment regimen selected above:
READINESS Please indicate which of the following scales/assessment tools was used to evaluate the readiness of the patient (only one is required): SAMHSA-HRSA – & – SAMSHA-HRSA C (PREP-C) – CONTINUATION THERAPY REQUESTS **This portion is not required for initial therapy requests 4 (±2 HCV RNA 12 HCV RNA Has documentation confirming HCV RNA levels at the appropriate week been submitted? Yes No Has the patient completed all HCV evaluation appointments and procedures and demonstrated compliance to their treatment regimen? Yes No CURRENT TREATMENT REGIMEN Please indicate the Sovaldi combination treatment regimen that is being prescribed: *For patients with HCV/HIV-1 co-infection, follow the dosage recommendations ^Recommended treatment regimen and duration for pediatric patients who are ≥ 12 years of age or weigh ≥ 35kg. **Consider screening for the presence of NS5A polymorphisms at amino acid positions M28, Q30, L31, and Y93 in patients with cirrhosis who are infected with HCV genotype 1a prior to the initiation of treatment with Daklinza and Sovaldi with or without RBV. ¥Consider screening for the presence of NS 3Q80K polymorphism in patients who are infected with HCV genotype 1a prior to initiation of treatment with Olysio and Sovaldi. Please provide dosing information for the treatment regimen selected above:
NYRx_PDP_PA_Worksheet_Prescribers_Sovaldi.docx