Proprotein Convertase Subtilisin/kexin Type 9(Pcsk9) Inhibitors - Medical Necessity Request Form

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Proprotein Convertase Subtilisin/kexin type 9(PCSK9) Inhibitors – Medical Necessity Request
Complete pages 1 and 2 for Initial request and page 3 for Subsequent request
General Questions:
1.
What is the specialty of the prescriber?
□ Cardiologist
□ Lipidologist
□ Other _______________________
2.
If member is female: Is the member pregnant? Yes or No
3.
Will the member be receiving another PCSK-9 inhibitor? Yes or No
Please provide the the member’s LDL-C levels
4.
a.
Pretreatment LDL-C levels_______________ *Please fax over lab report or office notes confirming this level.
b.
Current (past 30 days) LDL-C levels ___________________
date taken___________________ *Please fax over
lab report confirming this level.
5.
Has member tried any statins? Yes or No
If Yes, please provide name of medications__________________________________________________________________
Strength______________________________________________________________________________________________
Dates filled____________________________________________________________________________________________
Pharmacy name: _______________________________________________________________________________________
Pharmacy phone number and answer #6: ___________________________________________________________________
If No, Can member try high intensity Statin? (i.e. rosuvastatin 20-40mg or atorvastatin 40-80mg)? Yes or No
If yes, please call the pharmacy, then return form to HNJH
If no, please provide clinical reason why? ___________________________________________________________
Please send in the documentation (such as copy of chart or lab data) regarding why member is not able to take statins
6.
Will the member be receiving maximally tolerated statin with PCSK9-Inhibitor? Yes or No
If No, please provide clinical reason why? ________________________________________________________________
7.
Is member currently receiving Ezetimibe (Zetia) along with maximally tolerated statin for at least past 90 days? Yes or No
If yes, please provide dates filled _______________________________________________________________________
Pharmacy name_____________________________________________________________________________________
Pharmacy phone number and answer # 9__________________________________________________________________
If No, Can member try Zetia? Yes or No
If yes, please call the pharmacy, then return form to HNJH
If no, please provide clinical reason why? _____________________________________________________________
8.
Will the member be receiving Zetia with PCSK9-Inhibitor? Yes or No
If No, please provide clinical reason why? ________________________________________________________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office
1 of 3
Rev. 3/16
HNJH Fax #: 888-567-0681
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