This is the text extract for SA0796 – Ezetimibe, browse documents here.

---

Ministry of Health Phone 0800 243 666 APPLICANT (stamp or sticker acceptable)

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 1

Form SA0796

September 2010

PATIENT NHI: ...................................................... REFERRER Reg No: ............................................

Reg No: ................................................................ First Names: ......................................................... First Names: ......................................................... Name: ................................................................... Surname: .............................................................. Surname: .............................................................. Address: ............................................................... DOB: ..................................................................... Address: ............................................................... ............................................................................... Address: ............................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... Fax Number: ......................................................... ............................................................................... Fax Number: .........................................................

Ezetimibe

INITIAL APPLICATION Applications only from a relevant specialist. Approvals valid for 2 years. Prerequisites (tick boxes, and write the data requested in the space provided where appropriate)

or

u u

ezetimibe is to be used in combination with simvastatin ezetimibe is to be used without a statin

and

and and

u u

Patient has a calculated absolute risk of cardiovascular disease >20% over 5 years Patient cannot tolerate statin therapy at a dose of ≥ 40 mg per day

and and

u

Patient has venous CABG

LDL cholesterol: ......................................≥ 2 mmol/litre (see note) LDL cholesterol: ......................................≥ 2 mmol/litre (at least 1 week after test 1 – see note) or

and and

u

Patient does not have venous CABG

LDL cholesterol: ......................................≥ 2.5 mmol/litre (see note) LDL cholesterol: ......................................≥ 2.5 mmol/litre (at least 1 week after test 1 – see note) or

and and and

u u

Patient has homozygous familial hypercholesterolemia, or heterozygous familial hypercholesterolemia Patient has been compliant for at least two months with maximum dose statin therapy

LDL cholesterol: ......................................≥ 5 mmol/litre (see note) LDL cholesterol: ......................................≥ 5 mmol/litre (at least 1 week after test 1 – see note) Note: Two lipid tests are required to assess LDL cholesterol levels, the tests must be at least one week apart, and be carried out in a fasted state (other than for patients with IDDM). The results for LDL cholesterol levels in both tests must be above those specified.

Use next page for: Renewal I confirm the above details are correct and that in signing this form I understand I may be audited. Signed: .............................................................................. Date: ...............................................

Post application to Ministry of Health, Private Bag 3015, Wanganui – Fax: 0800 100 131

---

Ministry of Health Phone 0800 243 666 APPLICANT (stamp or sticker acceptable)

APPLICATION FOR SUBSIDY BY SPECIAL AUTHORITY

Page 2

Form SA0796

September 2010

PATIENT NHI: ...................................................... REFERRER Reg No: ............................................

Reg No: ................................................................ First Names: ......................................................... First Names: ......................................................... Name: ................................................................... Surname: .............................................................. Surname: .............................................................. Address: ............................................................... DOB: ..................................................................... Address: ............................................................... ............................................................................... Address: ............................................................... ............................................................................... ............................................................................... ............................................................................... ............................................................................... Fax Number: ......................................................... ............................................................................... Fax Number: .........................................................

Ezetimibe - continued

RENEWAL Current approval Number (if known):............................................................... Applications only from a relevant specialist. Approvals valid for 2 years. Prerequisites (tick boxes where appropriate)

and

u u u

or

The treatment remains appropriate and the patient is benefiting from treatment

ezetimibe is to be used in combination with simvastatin ezetimibe is to be used without a statin

I confirm the above details are correct and that in signing this form I understand I may be audited. Signed: .............................................................................. Date: ...............................................

Post application to Ministry of Health, Private Bag 3015, Wanganui – Fax: 0800 100 131