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.
VICTORIAN BRITAIN When we describe Great Britain in the Victorian period, words like stability,progress, prosperity, reform, and Imperialism come to mind. The British had grounds forsome satisfaction because evidence of great economic growth and technical progressseemed to abound. Despite the continued existence of widespread poverty, teeming,miserable slums and poor working conditions in many i
ASSURANCE ACCIDENTS CONDITIONS GÉNÉRALES D’ASSURANCE (CGA) TABLE DES MATIÈRES DISPOSITIONS COMMUNES ASSURANCE POUR ENFANTS ET JEUNES ASSURANCE POUR ADULTES ET SENIORS GENERALI Assurances Générales – Genève TABLE DES MATIÈRES 1. DISPOSITIONS COMMUNES H Assurance «allocation au décès » Objet du contrat H 1 Personnes assuréesH 2 Sommes assurées B Di
Specialty Pharmacy Provider:________________
Date: ___________ Date Medication Required:____________
Phone: (855) 535-1815 
Phone: (855) 535-1815