Proprotein Convertase Subtilisin/kexin Type 9(Pcsk9) Inhibitors - Medical Necessity Request Form Page 2

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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: __________________
Diagnosis Information (please indicate diagnosis and answer related questions):
□ Homozygous familial hypercholesterolemia (HoFH) **Note, if member also has Clinical Atherosclerotic Cardiovascular Disease
(ASCVD), please also answer the ASCVD questions below
a.
Will the member be receiving lomitapide (Juxtapid) or mipomersen (Kynamro) concurrently with this medication? Yes or No
b.
How was the diagnosis confirmed (e.g., genetic tests, labs, symptoms)?______________________________________________
Please send in the documentation (such as copy of chart or lab data) confirming it
□ Heterozygous familial hypercholesterolemia (HeFH) **Note, if member also has Clinical Atherosclerotic Cardiovascular
Disease (ASCVD), please also answer the ASCVD questions below
a. How was the diagnosis confirmed (e.g., genetic tests, labs, symptoms)?___________________________________________
Please send in the documentation (such as copy of chart or lab data) confirming it
□ Clinical Atherosclerotic Cardiovascular Disease (ASCVD) **Please send documentation (such as copy of chart) confirming
member’s diagnosis.
a. What is the member’s diagnosis?_______________________________________________________________________
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. 3/16
HNJH Fax #: 888-567-0681
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