Fillable Drug Prior Authorization Form Praluent (alirocumab), Repatha (evolocumab) (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Drug Prior Authorization Form Praluent (alirocumab), Repatha (evolocumab) (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Page 1 of 7(Continued on next page)
Plan Member’s signature: Date:
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M6453(REPAPRAL)-8/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
Drug Prior Authorization Form
Praluent (alirocumab), Repatha (evolocumab)
The purpose of this form is to obtain information required to assess your drug claim.
IMPORTANT: Please answer all questions. Your claim assessment will be delayed if this form is incomplete or contains errors.
Any costs incurred for the completion of this form are the responsibility of the plan member/patient.
Canada Life recognizes and respects the importance of privacy. Personal information collected is used for the purposes of
assessing eligibility for this drug and for administering the group benets plan. For a copy of our Privacy Guidelines, or if you have
questions about Canada Life’s personal information policies and practices (including with respect to service providers), refer to
www.canadalife.com or write to Canada Life’s Chief Compliance Ofcer.
I authorize Canada Life, any healthcare provider, my plan administrator, any insurance or reinsurance company, administrators of
government benets or patient assistance programs or other benets programs, other organizations, or service providers working with
Canada Life or any of the above, located inside or outside Canada, to exchange personal information when relevant and necessary for
these purposes. I understand that personal information may be subject to disclosure to those authorized under applicable law within
or outside Canada.
I acknowledge that the personal information is needed to assess eligibility for this drug and to administer the group benets plan.
I acknowledge that providing consent will help Canada Life to assess my claim and that refusing to consent may result in delay or
denial of my claim. Canada Life reserves the right to audit the information provided on this form at any time and this consent extends
to any audit of my claim. This consent may be revoked by me at any time by sending written instruction to that effect.
I also consent to the use of my personal information for Canada Life and its afliates’ internal data management and analytics purposes.
If the patient is a person other than myself, I conrm that the patient has given their consent to provide their personal information and
for Canada Life to use and disclose it as set out above.
I certify that the information given below is true, correct, and complete to the best of my knowledge. Failure to provide true, correct
and complete information on this form could result in revocation of any approval decision, a requirement to repay paid claims or other
appropriate action.
Form Completion Instructions:
1. Complete “Patient Information” sections.
2. Have the prescribing physician complete the “Physician Information” sections.
3. Send all pages of the completed form to us by mail, fax or email as noted below.
Note: As email is not a secure medium, any person with concerns about their prior authorization form/medical information being
intercepted by an unauthorized party is encouraged to submit their form by other means.
Mail to: The Canada Life Assurance Company
Drug Claims Management
PO Box 6000
Winnipeg MB R3C 3A5
Fax to: The Canada Life Assurance Company
Fax 1-204-946-7664
Attention: Drug Claims Management
Email to: cldrug.services@canadalife.com
Attention: Drug Claims Management
For additional information regarding Prior Authorization and Health Case Management, please visit our Canada Life website at
www.canadalife.com or contact Group Customer Contact Services at 1-800-957-9777. Deaf or hard of hearing and require access to
a telecommunications relay service? Please contact us at 711 for TTY to Voice or 1-800-855-0511 for Voice to TTY.
Praluent (alirocumab), Repatha (evolocumab)
– (please print)
Plan Member: Patient Name:
Plan Name: Plan Number: Plan Member ID Number:
Patient Date of Birth (DD/MM/YYYY): Address (number, street, city, province, postal code):
Please indicate preferred contact number and if there are any times when telephone contact with you about your claim would be most convenient.
• • If yes, please provide email address:
• •
If Yes, a) indicate start date (DD/MM/YYYY):
b) coverage provided by:
(if coverage is not provided by Canada Life please provide pharmacy print-out showing purchase of this drug)
• •
If Yes, name of other Insurance Company:
If other plan is with Canada Life, tell us the plan and ID number:
Name of plan member:
Relationship to patient:
Provide details and attach documentation of acceptance or decline:
• •
If Yes, name of program or other source:
Provide details and attach documentation of acceptance or decline:
• •
• •
1. Patient assistance program patient ID Number:
Contact Name: Phone Number:
M6453(REPAPRAL)-8/20
(Continued on next page)
Page 2 of 7
Patient Information
Plan Member Information Complete all sections of this page
May we contact you by email? (Note that some correspondence may still need to be sent by regular mail).
Yes No
Tell us if you have been on this drug before
Is the patient currently on, or previously been on this drug? Yes No
Tell us if you have coverage with any other benefits plan
Does the patient have drug coverage under any other group benets plan? Yes No
Tell us about any Provincial or other coverage you may have
Does the patient have coverage under a provincial program or from any other source? Yes No
Is the patient currently receiving disability benets for the condition for which this drug has been prescribed? Yes No
Tell us about any Patient Assistance Program you might be enrolled in
Has the patient enrolled in the patient assistance program for this drug? Yes No
If Yes, please provide the following information:
2. Patient assistance program contact person name and phone number:
Praluent (alirocumab), Repatha (evolocumab)
(please print)
Name of prescribing physician:
Specialty:
Address (number, street, city, province, postal code):
Telephone Number (including area code): Fax Number (including area code):
n
n
2. Health Canada indication (include date of initial diagnosis) (MM/YYYY):
1
n
1
n
1
2
n
2
n
2
n
2
n
M6453(REPAPRAL)-8/20
(Continued on next page)
Page 3 of 7
Physician Information
Note to Physician: In order to assess a patient’s claim for this drug, we require detailed information on the patient’s
prescription drug history as requested below.
Attach extra information if necessary. GENETIC TEST RESULTS ARE NOT REQUIRED
Physician’s Information
1. Prescribed Medication:
Praluent (alirocumab)
Repatha (evolocumab)
Approved Health Canada Indications and Clinical Use for Praluent:
Prevention of Cardiovascular Events
Praluent (alirocumab injection) is indicated in combination with a maximum tolerated dose of a statin, with or without other lipid lowering
therapies, to reduce the risk of myocardial infarction, ischemic stroke, and unstable angina requiring hospitalization in adults with established
cardiovascular disease.
Primary Hyperlipidemia
Praluent (alirocumab injection) is indicated for the reduction of low density lipoprotein cholesterol (LDL-C) in adults with primary hyperlipidemia
(heterozygous familial and non-familial):
• As an adjunct to diet and statin therapy, with or without other lipid-lowering therapies;
• As an adjunct to diet, as monotherapy or in combination with other non-statin lipid-modifying therapies, in patients for whom a statin is contraindicated
Approved Health Canada Indications and Clinical Use for Repatha:
Prevention of Cardiovascular Events
Repatha is indicated as an adjunct to diet and standard of care therapy (including moderate- to high-intensity statin therapy alone or in
combination with other lipid-lowering therapy), to reduce the risk of myocardial infarction, stroke, and coronary revascularization in adult
patients with atherosclerotic cardiovascular disease
Primary Hyperlipidemia (including Heterozygous Familial Hypercholesterolemia)
Repatha is indicated for the reduction of elevated low density lipoprotein cholesterol (LDL-C) in adult patients with primary hyperlipidemia
(including heterozygous familial hypercholesterolemia):
• as an adjunct to diet and statin therapy, with or without other lipid-lowering therapies, in patients who require additional lowering of LDL-C
• as an adjunct to diet, alone or in combination with non-statin lipid-lowering therapies, in patients for whom a statin is contraindicated
Homozygous Familial Hypercholesterolemia
Repatha is indicated as an adjunct to diet and other LDL-lowering therapies (e.g., statins, ezetimibe, LDL apheresis) in adult patients and
adolescent patients aged 12 years and over with homozygous familial hypercholesterolemia (HoFH) who require additional lowering of LDL-C.
Other (approved by Health Canada):
Complete questions 1 - 7 and Other condition (Health Canada approved)
Physician Information
Praluent (alirocumab), Repatha (evolocumab)
Physician’s Information (continued) (please print)
1,2
n
n
Prescribed dosage and regimen:
Provide rationale
3. What is the anticipated duration of treatment with this drug?
• • • • •
5. Please provide medical rationale why this drug has been prescribed instead of an alternate drug in the same therapeutic class.
• • •
Clinical details:
• • •
Clinical details:
•
•
•
•
•
•
•
•
•
M6453(REPAPRAL)-8/20
(Continued on next page)
Page 4 of 7
Is this drug being prescribed in accordance with approved Health Canada indications ?
Yes, complete questions 1 – 7 and Physician’s Information
No, prescribed use is not approved by Health Canada:
Complete questions 1 – 7 and Off-label use
4. Where will treatment be administered? Home Physician’s Ofce Private clinic Hospital in-patient Hospital out-patient
6. Drug and Treatment History – must be completed for every request.
NON-STATIN Drug History
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Failure Intolerance Other
Failure Intolerance Other
STATIN Drug History
Name of Statin Dosing Regimen
Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Or Currently On
Patient responses:
Reason for discontinuation, Details of
intolerance, or failure at maximum tolerated
dose must be provided
Persistent myopathy or myalgia for at least
2 weeks
Myositis or Rhabdomyolysis
Other - please detail:
Persistent myopathy or myalgia for at least
2 weeks
Myositis or Rhabdomyolysis
Other - please detail:
Persistent myopathy or myalgia for at least
2 weeks
Myositis or Rhabdomyolysis
Other - please detail:
Physician Information
Praluent (alirocumab), Repatha (evolocumab)
Physician’s Information (continued) (please print)
• •
•
•
•
•
–
• •
• •
• •
•
•
• •
-
• •
• •
M6453(REPAPRAL)-8/20
(Continued on next page)
Page 5 of 7
7. STATIN history questions
a. Is the patient currently taking a maximally-tolerated dose of statin therapy for at least 4 weeks and is expected to continue on statin
therapy? Yes No
b. Does patient have any contraindications to statin use, such as pregnancy, breast feeding, active liver disease or unexplained persistent
elevations of serum transaminases exceeding 3x upper limit of normal?
Yes – please list contraindication:
No
c. Is patient considered intolerant to statins?
Yes – please ensure details of intolerance to at least 2 different statins is documented in the STATIN history chart on the previous page
No
Prevention of Cardiovascular Events Genetic test results are not required
Patient’s ASCVD history:
Acute coronary syndromes
History of myocardial infarction (MI)
Stable or unstable angina
Coronary or other arterial revascularization
Stroke
Transient ischemic attack (TIA)
Peripheral arterial disease presumed to be of atherosclerotic origin
Please submit the listed reports to assist with the review:
Patient’s most recent LDL-C lab result (must be current within 6 months of application)
Will the patient be following a low cholesterol diet while taking Praluent/Repatha? Yes No
Primary Hyperlipidemia Genetic test results are not required
Has patient been diagnosed with heterozygous familial hypercholesterolemia or another form of primary hyperlipidemia? Yes No
Please submit the listed reports to assist with the review:
• Most recent LDL test result (must be current within 6 months of application)
• Laboratory results and clinic notes that support the diagnosis and describe the patient’s clinical manifestations of
disease
Will the patient be following a low cholesterol diet while taking Praluent/Repatha? Yes No
Physician Information
Praluent (alirocumab), Repatha (evolocumab)
Physician’s Information (continued) (please print)
– –
n
n
n
n n
–
Please provide any relevant information related to the disease and attach supporting documentation.
–
n n
Provide medical rationale why this drug has been prescribed off-label instead of an alternate drug with an approved indication for this condition.
Provide any pertinent medical history or information to support this off-label request.
If this is a renewal request, provide documentation showing treatment efcacy since previous request.
M6453(REPAPRAL)-8/20
Page 6 of 7
Homozygous Familial Hypercholesterolemia (HoFH) Repatha only Genetic test results are not required
Has the diagnosis been conrmed by any of the following? (check all that apply)
History of untreated elevated LDL-C concentration > 13 mmol/L
Xanthoma before 10 years of age.
Evidence of heterozygous familial hypercholesterolemia in both parents
Please submit the listed reports to assist with the review:
• Patient’s most recent LDL-C level (must be current within 6 months of request date)
• Untreated elevated LDL-C concentration >13 mmol/L
Will the patient be following a low cholesterol diet while taking Repatha? Yes No
Other condition (Health Canada approved) Genetic test results are not required
Off-label use Genetic test results are not required
Questions 1-7 must be completed.
Is there clinical evidence supporting the off-label use of this drug? Yes No
Provide clinical literature/studies to support the request for off-label use, such as:
• At least two Phase II or two Phase III clinical trials showing consistent results of efcacy; and
• Published recommendations in evidence-based guidelines supporting its use.
Physician Information
Praluent (alirocumab), Repatha (evolocumab)
Physician’s Signature: Date:
License Number:
M6453(REPAPRAL)-8/20
Page 7 of 7
Note for Physician: To be eligible for reimbursement, Canada Life may require your patient to purchase a drug requiring prior
authorization from a pharmacy designated by Canada Life. If applicable, a health case manager will contact you with further
information.
I certify that the information provided is true, correct, and complete.
It is important to provide the requested information in detail to help avoid delay in assessing claims for the above drug. This form may
be subject to audit. The completed form can be returned to Canada Life by mail, fax, or email.
Note: As email is not a secure medium, any person with concerns about their prior authorization form/medical information being
intercepted by an unauthorized party is encouraged to submit their form by other means.
Mail to: The Canada Life Assurance Company
Drug Claims Management
PO Box 6000
Winnipeg MB R3C 3A5
Fax to: The Canada Life Assurance Company
Fax 1-204-946-7664
Attention: Drug Claims Management
Email to: cldrug.services@canadalife.com
Attention: Drug Claims Management
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Drug Prior Authorization Form Praluent (alirocumab), Repatha (evolocumab) (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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