Referal Form ⸻ LEQVIO LEQVIO® Referral/Order Form If the preferred treatment center does not have its own required referral/order form, you may use this form when referring your LEQVIO patient to help support the order. This form is meant to capture the most common information typically needed by a treatment center. NOTE: You should check with the treatment center directly to confirm the process for referral and information required before completing this document. INDICATION LEQVIO injection is indicated as an adjunct to diet and statin therapy for the treatment of adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH), to reduce low-density lipoprotein cholesterol (LDL-C). Preferred treatment center name: DOB: Address: ► PATIENT please attach patient demographic form if available) Name: Date: Address: City: State: ZIP Code: Phone: Email: No known drug allergiesAllergies: INSURANCE INFORMATION REQUIRED-Front and back copies of all patient insurance cards: primary, secondary (if applicable), and prescription (if applicable). Select all that apply: PrimarySecondaryPrescription/Pharmacy ► PROVIDER INFORMATION Referring Provider Name: NPI #: Practice Name: Office Contact Name: Address: City: State: ZIP Code: Phone: Fax: Email: ► CLINICAL INFORMATION 1. Primary diagnosis section (must select one; complete ICD-10-CM to highest level of specificity) - REQUIRED I confirm the patient has been currently receiving statin therapy (or has been determined clinically intolerant) and has been diagnosed with: E78 OR E78.01 Familial hypercholesterolemia (eg, HeFH) OR Other (specify ICD-10-CM): Hyperlipidemia (E78.00, E78.2, E78.4, E78.49, E78.5) | | | | | | | | | Z83.42 Family history of familial hypercholesterolemia E75.5 Other lipid storage disorders (approximate synonyms include tendon xanthoma) | | | | | | | Other (supporting documents include Simon Broome diagnostic, Dutch Lipid Clinic score, and/or genetic testing) 2. Secondary diagnosis(es) (please complete if Hyperlipidemia above is selected; complete ICD-10-CM to highest level of specificity) - RECOMMENDED Clinical ASCVD: AND/OR Other clinical risk factors: I2 I6 I70 I73 Other E11. I10. Other 3. LDL-C level: Current level: Date taken: Current LDL-C lowering treatment(s): Patient status and treatment history Include patient chart notes to support documentation payers may require, such as: • Clinical documentation for specified ICD-10-CM diagnosis codes • Recent comprehensive lipid panel/LDL-C values (in the last 90 days) • Statin history and/or additional lipid-lowering treatment • Statin intolerance (if applicable) • Counseling on the importance of lifestyle modifications including diet and exercise Patient was previously enrolled in an inclisiran clinical trial. Last inclisiran injection date: ► LEQVIO ORDER (select all that apply) - Order valid for 1 year from provider signature date Initial dose → LEQVIO (inclisiran) 284 mg/1.5 mL subcutaneous initially, then LEQVIO (inclisiran) 284 mg/1.5 mL subcutaneous in 3 months Maintenance dose → LEQVIO (inclisiran) 284 mg/1.5 mL subcutaneous every 6 months Other → LEQVIO (inclisiran) 284 mg/1.5 mL subcutaneous Previous LEQVIO dose given on: Date: ► PROVIDER SIGNATURE: Date: IMPORTANT SAFETY INFORMATION Adverse reactions in clinical trials (≥3% of patients treated with LEQVIO and more frequently than placebo) were injection site reaction, arthralgia, and bronchitis. Please click here for LEQVIO full Prescribing Information. Please prove you are human by selecting the plane.
