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Oral oncology referral form

 Specialty Pharmacy Provider:________________ Date: ___________ Date Medication Required:____________ Phone: (855) 535-1815
Ship to:  Physician  Patient’s Home  Other __________ Fax: (855) 815-9894
Prior Authorization Form
Juxtapid
Patient Name: ___________________________________________________ Physician Name: _______________________________________________ Address: _______________________________________________________ State Lic #______________________ DEA # ________________________ City: ________________________________State: _______Zip:____________ NPI # _________________________ Specialty: _____________________ Home Phone: (___________) ___________ - _________________________ Practice Name/Hospital: _________________________________________ Work Phone: (_______) _____________ - _________________________ Address: _____________________________________________________ Cell Phone: (__________) _____________ - _________________________ City: __________________________ State: ________ Zip: ____________ Patient Soc. Sec #: _________________ Al ergies:_______________________ Physician’s Ph: (__________) ____________ - ______________________ Date of Birth: ___/___/___ Sex:  Male Female Weight _____ lbs kg Physician’s Fax: (__________) ____________ - _____________________ Height: _______ BSA: ________ m² See attached demographic sheet Nurse/Key Of ice Contact: ________________________________________ IN SURANCE INFORMATION (Complete or At ach Copies of cards)
DIAGNOSIS (Required)
 Homozygous Familial Hypercholesterolemia (HoFH)  Other: _______________________________ What is the ICD9 / ICD10 code? ________________________
PATIENT EVALUATION
1. Does the patient have a history of untreated total cholesterol level greater than 500 mg/dL?  Yes  No If No, skip to #4 2. Does the patient have a history of untreated triglyceride level less than 300 mg/dL?  Yes  No If No, skip to #4 3. Do both of the patient’s parents have a history of untreated total cholesterol level greater than 250 mg/dL? Yes  No  Unknown 4. Does the patient have documented mutations in both low-density lipoprotein (LDL) receptor alleles?  Yes  No If Yes, attach documentation and skip to #6 5. Does the patient have documented skin fibroblast low-density lipoprotein (LDL) receptor activity less than 20% of normal? If Yes, attach documentation and skip to #6 6. Is the patient receiving lipid-lowering treatment (eg, low-density lipoprotein [LDL], atorvastatin [Lipitor], pitavastatin [Livalo], rosuvastatin [Crestor], simvastatin [Zocor], cholestyramine [Questran], colesevelam [Welchol], colestipol [Colestid], ezetimibe [Zetia], nicotinic acid [Niacin], gemfibrozil [Lopid], or fenofibrate [Tricor, Triglide])? 7. Is the patient on a low-fat diet?  Yes  No 8. Does the patient have moderate or severe hepatic impairment?  Yes  No 9. Wil the patient be monitored regularly for liver toxicity as specified in the prescribing information?  Yes  No 10. Wil Juxtapid be given together with any of the following strong or moderate CYP3A4 inhibitors?  Yes No Boceprevir [Victrelis], telaprevir [Incivek] Ciprofloxacin [Cipro], clarithromycin [Biaxin], erythromycin [Eryc, Ery-Tab], telithromycin [Ketek] Amprenavir [Agenerase], atazanavir [Reyataz], darunavir [Prezista], fosamprenavir [Lexiva], indinavir [Crixivan], lopinavir/ritonavir [Kaletra], nelfinavir [Viracept], ritonavir [Norvir], saquinavir [Invirase] Fluconazole [Diflucan], itraconazole [Sporanox], ketoconazole, posaconazole [Noxafil], voriconazole [Vfend] Conivaptan [Vaprisol], diltiazem [Cardizem, Cartia XT®, Dilacor XR®, Diltia XT®, Diltzac, Matzim® LA; Taztia XT®], mibefradil [Posicor], verapamil [Isoptin, Crizotinib [Xalkori], imatinib [Gleevec] 11. What is the gender of the patient?  Female  Male If Male, no further questions
Continued on the next page…
12. Is the patient of childbearing potential?  Yes  No If No, no further questions Phone: (855) 535-1815
Fax: (855) 815-9894
Patient Name:__________________________ 13. Is the patient pregnant? If Yes, no further questions  Yes  No 14. Wil the patient use adequate contraception while on Juxtapid therapy?  Yes  No **NOTE: We can NOT make a decision without a copy of pertinent lab results and/or the current clinical progress notes - Thank You**
MEDICATION
STRENGTH
DIRECTIONS
QUANTITY

Physician’s Signature: __________________________________________________________Date____/_____/____

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under
applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to
disposal of the transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.

Source: http://www.nhhealthyfamilies.com/files/2013/12/Juxtapid-PA-Form_20131204.pdf

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