Section1 � Prescriber Information & Mailing Address by WJQQY8G


									Exceptional Access Program (EAP) Request Form: Chronic Hepatitis C Treatments
 Section1 – Prescriber Information & Mailing Address Section 2 – Patient Information
 First Name                 Initial   Last name      First Name     Initial   Last name

 Street no.              Street Name                                               Health Card Number

 City                                                    Postal Code

 Fax Number                                     Telephone Number                   Date of Birth (yyyy/mm/dd)

 Section 3 – Drug(s) Requested
 Patient’s weight (kg):                        Expected Start Date (yyyy/mm/dd):
 PEGETRON:        REDIPEN       VIAL (Note doses below are per Product                        VICTRELIS TRIPLE (Combination pack - for Genotype 1 only)
                                                                                              Treatment Naïve                          Treatment Experienced
 Weight Non-G1, Tx Naïve      G-1, Tx Experienced Weight G-1, Tx Naïve
                                                                                                 40-50 kg: 80mcg/800mg/2400mg             40-50 kg: 80mcg/800mg/2400mg
 < 40 kg       50mcg/800mg        50mcg/800mg      < 40 kg       50mcg/800mg                     51-65 kg: 100mcg/800mg/2400mg            51-65 kg:100mcg/800mg/2400mg
 40-50 kg      80mcg/800mg        80mcg/800mg      40-50 kg      80mcg/800mg                     66-80 kg: 120mcg/1000mg/2400mg           66-85 kg:120mcg/1000mg/2400mg
 51-65 kg      100mcg/800mg       100mcg/800mg 51-65 kg          100mcg/800mg                    81-105 kg: 150mcg/1200mg/2400mg          86-105 kg:150mcg/1200mg/2400mg
 66-85 kg      120mcg/1000mg      120mcg/1000mg 66-80 kg         120mcg/1000mg                   >105 kg: 150mcg/1400mg/2400mg            >105 kg: 150mcg/1400mg/2400mg
 86-105 kg     150mcg/1200mg      150mcg/1200mg 81-105 kg        150mcg/1200mg
 >105 kg      150mcg/1200mg       150mcg/1400mg >105 kg          150mcg/1400mg
 PEGASYS RBV:                                                                                 VICTRELIS (boceprevir):
     180 mcg/0.5 mL PFS + RBV               180 mcg/mL vial + RBV                                800 mg tid
 Section 4 – Clinical Information
 Genotype:  Genotype 1 (only genotype 1 is reimbursed for boceprevir)                         Genotype 2, 3 Other:                ______________________
 HCV RNA quantitative value (one level within past 6 months required): Date (yyyy/mm/dd): ___________ Result: _______________
 Cirrhosis: No cirrhosis        Cirrhosis - provide Child-Pugh score: 5-6 (A)                7-9 (B)*      ≥10 (C)
  * Provide a breakdown of the CP score if the patient has CP score of B: _____________________________________________________
 Fibrosis Metavir stage: F1           F2 F3 F4
 Fibrosis determined by:         Liver biopsy Fibroscan Fibrotest                                Date: (yyyy/mm/dd):________________________________

 Section 5 – Previous Medications
 Previous treatment:        Treatment Naïve – Skip to Section 6 if treatment naïve
 Peginterferon alfa and ribavirin Peginterferon monotherapy Interferon and ribavirin Interferon monotherapy
 Start Date of previous treatment (yyyy/mm/dd):___________________ Duration of previous treatment: __________________
 Response to previous treatment:
  Relapser             Partial responder or Non-responder Intolerance                       (Specify/describe: ________________________________ )
 Section 6 – Lab values – Must be within past 6 months
              Lab                Date (yyyy/mm/dd)                   Result             If requesting peginterferon alfa and ribavirin dual therapy for a patient with
                                                                                        genotype other than 2 or 3 AND the patient does not have fibrosis metavir
 Hemoglobin                                                                             stage F2 or higher, please provide 2 ALT results within the previous six
 WBC                                                                                    months with normal ranges and dates. Any other relevant bloodwork may
                                                                                        also be listed below as applicable:
 Albumin                                                                                Lab                         Date (yyyy/mm/dd)              Result
                                                                                        ________________           ____________________            _________________
                                                                                        ________________           ____________________            _________________
                                                                                        ________________           ____________________            _________________
 Bilirubin (direct)

 Section 7 – Additional Information
 1. Is the patient a null responder (< 2 log drop in HCV RNA by TW12) to previous treatment with peginterferon alfa/ribavirin? Yes                                   No
 2. Does the patient have Hepatitis B co-infection?                Yes         No
 3. Is the patient HIV positive?                                   Yes        No
 4. Does the patient currently have decompensated liver disease? Yes          No
 5. Has the patient had an organ transplant (including liver)?     Yes (Specify organ) ____________________________________)                                         No
 6. Does the patient have any other comorbid conditions?           Yes (Specify:___________________________________________)                                         No
 Prescriber Signature (mandatory)                              CPSO number                                        Date (yyyy/mm/dd)

Fax the completed form and/or any additional/relevant information to (416) 327-7526 or toll-free to 1-866-811-9908; or send your request to the Ontario Public Drug
Programs, Exceptional Access Program Branch, 3rd Floor, 5700 Yonge Street, Toronto, ON, M2M 4K5.

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