Juxtapid (Lomitapide) Prior Authorization Of Benefits (Pab) Form

CONTAINS CONFIDENTIAL PATIENT INFORMATION

Juxtapid (lomitapide)

Prior Authorization of Benefits (PAB) Form

Complete form in its entirety and fax to:

Prior Authorization of Benefits Center at (800) 601- 4829

1. PATIENT INFORMATION

2. PHYSICIAN INFORMATION

Patient Name: __________________________________

Prescribing Physician: ____________________________

Patient ID #:

__________________________________

Physician Address:

_____________________________

Patient DOB: __________________________________

Physician Phone #:

_____________________________

Date of Rx:

__________________________________

Physician Fax #:

_____________________________

Patient Phone #: _______________________________

Physician Specialty:

____________________________

Patient Email Address: ___________________________

Physician DEA:

____________________________

Physician NPI #:

_____________________________

Physician Email Address: ___________________________

3. MEDICATION

4. STRENGTH

5. DIRECTIONS

6. QUANTITY PER 30 DAYS

________________

Juxtapid (lomitapide)

______________________

Specify: _________________

7. DIAGNOSIS: ___________________________________________________________________________________

CHECK ALL BOXES THAT APPLY

8. APPROVAL CRITERIA:

NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.

□

□

Yes

No

Patient has a diagnosis of Homozygous Familial Hypercholesterolemia (HoFH)

□

□

Yes

No

Patient has genetic confirmation of two (2) mutant alleles at the LDL receptor, ApoB, PCSK9 or ARH

adaptor protein gene locus

□

□

Yes

No

Patient has an untreated LDL-cholesterol concentration greater than 500 mg/dL (13 mmol/L)

□

□

Yes

No

Patient has a treated LDL-cholesterol greater than or equal to 300 mg/dL

□

□

Yes

No

Patient has cutaneous or tendonous xanthoma before age of 10 years

□

□

Yes

No

Patient has untreated LDL cholesterol levels consistent with heterozygous FH in

both parents (greater than 190 mg/dL)

□

□

Yes

No

Patient has had an inadequate trial and titration of Repatha and achieved suboptimal lipid lowering

response, despite at least 90 days of compliant therapy

□

□

Yes

No

Repatha is unacceptable due to concomitant clinical situations, such as but not limited to a known

disease state or medication contraindication which is not also associated with Juxtapid (lomitapide)

□

□

Yes

No

Juxtapid (lomitapide) is being used concurrently with PCSK-9 Inhibitors

□

□

Yes

No

Patient is 18 years of age or older

9. PHYSICIAN SIGNATURE

____________________________________________________________

__________________________________________

Prescriber or Authorized Signature

Date

Prior Authorization of Benefits is not the practice of medicine or the substitute for the independent medical judgment of a treating physician. Only a treating physician can determine what

medications are appropriate for a patient. Please refer to the applicable plan for the detailed information regarding benefits, conditions, limitations, and exclusions. The submitting

provider certifies that the information provided is true, accurate, and complete and the requested services are medically indicated and necessary to the health of the patient.

Note: Payment is subject to member eligibility. Authorization does not guarantee payment.

The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is intended only

for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other

party unless required to do so by law or regulation.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of

these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or

destruction of these documents.

Juxtapid NTL PAB Fax Form 12.04.15.doc