Form Gl2443 - Group Benefits Prior Authorization - Repatha (Evolocumab) - 2016

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GROUP BENEFITS

PRIOR AUTHORIZATION FORM

REPATHA (EVOLOCUMAB)

MAILING ADDRESS

INSTRUCTIONS

Mail:

Co-operators Life Insurance Company

If the drug you have been prescribed is listed under a provincial drug plan, you or your physician will

Extended Health Care Claims

need to apply and/or submit your claim to the applicable program before consideration is given under

1920 College Avenue

The Co-operators drug plan. If your claim is refused by your provincial drug plan, please provide

Regina SK S4P 1C4

proof of the application by including a copy of the refusal letter along with the form completed by your

physician so that your request can be reviewed further.

Fax:

(306) 761-7101

PART 1 - PATIENT INFORMATION

Group ____________________________________

Account _______________________________________

Certificate _____________________________________

Plan Member ___________________________________________________________ ________ ___________________________________________________________

First Name

Initial

Last Name

Patient _________________________________________________________________ ________ ___________________________________________________________

First Name

Initial

Last Name

Address _______________________________________________________ ____________________________________________ ________ _______________________

Street

City

Province

Postal Code

Date of Birth ____________________________

Relationship to Plan Member _________________________________________________________________________

MMM/DD/YYYY

PART 2 - PHYSICIAN INFORMATION

Physician ____________________________________ ________ _______________________________________

Specialty ____________________________________

First Name

Initial

Last Name

Address _______________________________________________________ ____________________________________________ ________ _______________________

Street

City

Province

Postal Code

Telephone Number ( ________ ) __________________________ Fax Number ( ________ ) __________________________

Name of Requested Drug _____________________________________________________

Dosing Schedule _______________________________________________

DIN _____________________________

Strength ________________________________

Expected Duration of Therapy ____________________________________

Most recent LDL-C level _______________________ mmol/L Anticipated Monthly Cost $ ______________________________

Please list all prior statin therapy and length of therapy ______________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

What is the patient’s diagnosis:

Heterozygous familial hypercholesterolemia (HeFH) confirmed using

Homozygous familial hypercholesterolemia (HoFH) confirmed by:

the Simon Broome criteria:

Patient had documented baseline LDL-C >13mmol/L at diagnosis

LDL-C level of > 4.9 mmol/L PLUS at least one of the following:

PLUS one of the following:

Physical finding = tendon xanthomas, or tendon xanthomas in first or

Physician has provided DNA-based evidence of two mutant alleles

second degree relative; OR

to confirm diagnosis; OR

DNA-based evidence of an LDL-receptor mutation, familial defective

Tendon xanthomas are present in the patient; OR

apo B-100, or a PCSK9 mutation; OR

Evidence of heterozygous familial hypercholesterolemia in both parents.

Family history of myocardial infarction before the age of:

Atherosclerotic Cardiovascular disease (ASCVD)

• 50 Years, in any first- or second-degree relative

• 60 Years, in any first-degree relative

Please provide documentation to confirm presence of HeFH or HoFH and attach patient’s cholesterol work-up or complete blood count

Does the patient have a documented history of one of the following cardiovascular events? If yes, check all that apply and provide documentation:

Acute coronary syndrome

Myocardial infarction

Stable/unstable angina

Transient ischemic attack/stroke

Peripheral arterial disease presumed to be of atherosclerotic origin

Coronary or other arterial revascularization procedure

Findings from CT angiogram or catheterization with clinical ASCVD

Does the patient have a documented prior therapy at least 3 months of the following?

High Intensity statin therapy (Atorvastatin 40-80mg, Rosuvastatin 20-40mg); OR

Therapeutic failure/intolerance/contraindication to at least two statins

If the patent has had no prior statin therapy or less than 3 months of therapy, why? _____________________________________________________________________

_____________________________________________________________________________________________________________________________________________

CO-OPERATORS LIFE INSURANCE COMPANY

GL2443 (04/16)

1920 COLLEGE AVENUE REGINA SK S4P 1C4

PG 1 of 2