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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: __________________

Complete this page for Subsequent Request

General Questions:

If member is female: Is the member pregnant? Yes or No

Will the member be receiving another PCSK-9 inhibitor? Yes or No

Will the member continue to receive the requested drug together with ezetimibe (Zetia)?

□ Yes

□ No – if not, why is the Zetia being discontinued:_____________________________________________________________

Will the member continue to receive the requested drug together with a maximum intensity statin (atorvastatin 40-80mg,

Rosuvastatin 20-40mg)?

□ Yes, please provide name of medications__________________________________________________________________

Dates filled____________________________________________________________________________________________

Pharmacy name: _______________________________________________________________________________________

Pharmacy phone number: ________________________________________________________________________________

□ No - if not,

a. Why is the statin being discontinued______________________________________________________________

b. Will a lower statin dose be prescribed instead?

□ Yes - Why is lower dose being use instead?________________________________________________

□ No - if not, why not____________________________________________________________________

Please provide the current LDL-C taken within the past 30 days and date taken.

- Level: _____________mg/dL

Date Taken: ______________ *Please fax over lab report confirming this level.

Diagnosis Information (please indicate diagnosis and answer related questions):

□ Homozygous familial hypercholesterolemia (HoFH)

Will the member be receiving lomitapide (Juxtapid) or mipomersen (Kynamro) concurrently with this medication? Yes or No

□ Heterozygous familial hypercholesterolemia (HeFH)

□ Clinical Atherosclerotic Cardiovascular Disease (ASCVD)

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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HNJH Fax #: 888-567-0681

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Proprotein Convertase Subtilisin/kexin Type 9(Pcsk9) Inhibitors - Medical Necessity Request Form Page 3