Ezetimibe (Zetia) - Medical Necessity Request Form printable pdf download

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________

Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________

Horizon NJ Health

Ezetimibe (Zetia) – Medical Necessity Request

1. What is the diagnosis?

□ Hypercholesterolemia/High cholesterol

□ Hyperlipidemia

□ Sitosterolemia/Phytosterolemia

□ Other: ________________________________________

a. Does the member have high lipid or cholesterol levels? Yes or No

2. Has the member tried and failed statin (HMG-CoA reductase inhibitor) therapy?

*HNJH formulary statins include: atorvastatin, pravastatin, simvastatin, and lovastatin.

□ Yes - Provide the name of the statin tried, then return form to HNJH: ____________________________

□ No - Would the physician consider prescribing a statin instead of or in addition to Zetia?

□ Yes – instead of Zetia: please call the statin prescription into the member’s pharmacy, then return

form to HNJH.

□ Yes – in addition to Zetia: please call the prescription into the member’s pharmacy, then return

form to HNJH.

□ No – please provide the clinical rationale for why the member cannot try/has tried statin therapy,

then go to Question #3.

___________________________________________________________________________

3. Will the member also be receiving a fibric acid derivative? Yes or No

*HNJH formulary fibric acid derivatives include: fenofibrate (Lofibra) and gemfibrozil (Lopid)

□ Yes - Provide the name of the drug tried, then return form to HNJH: ____________________________

□ No - would the physician consider prescribing a fibric acid derivative in addition to Zetia?

□ Yes – please call the fibric acid derivative prescription in to the member’s pharmacy, then return

form to HNJH.

□ No – please provide the clinical rationale for why the member cannot try/has tried a fibric acid

derivative

___________________________________________________________________________

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office

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Rev. 03/16

HNJH Fax #: 888-567-0681

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Ezetimibe (Zetia) - Medical Necessity Request Form