• LIPTRUZET Motivation Form

  • Welcome to the LIPTRUZET motivation form. 

    This tool is to assist you in compiling a comprehensive draft letter to request reimbursement of LIPTRUZET from the funder. It will be sent to your email for you to review and edit before submission to the funder. 

    This tool does not substitute independent medical judgement and approval is not guaranteed by Essential Medical Guidance (EMGuidance) or Organon. It is designed to guide and assist healthcare professionals (HCPs) in formulating a successful motivation for a LIPTRUZET reimbursement application. 

    The motivation form is intended to reduce funder reimbursement rejections of LIPTRUZET which is indicated for the prevention of cardiovascular events in patients with coronary heart disease (CHD) and a history of acute coronary syndrome (ACS) or for patients with hypercholesterolaemia or mixed hyperlipidaemia or homozygous familial hypercholesterolaemia (HoFH).

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  • Doctor Details

  • Format: (000) 000-0000.

  • The information is confidential and is securely stored by EMGuidance in accordance with the POPI Act. This information will only be used for the creation of a motivation letter. I understand that at any time I can request that EMGuidance correct or destroy my personal information or that of my patients that is in their possession by contacting EMGuidance at: support@emguidance.com.

  • Patient Details

  • Patient Gender*
  • Medical aid name*
  • Please select a Discovery Health Medical Scheme option*
  • Please select a Government Employees Medical Scheme (GEMS) option*
  • Please select a Bonitas Medical Fund option*
  • Please select a South African Police Service Medical Scheme (POLMED) option*
  • Please select a Momentum Health option*
  • Please select a Bankmed medical scheme option*
  • Please select a Medihelp medical scheme option*
  • Please select a LA-Health Medical Scheme option*
  • Please select a Bestmed Medical Scheme option*
  • Please select a Medshield Medical Scheme option*
  • Please select a Fedhealth Medical Scheme option*

  • Clinical Details

    As part of your motivation details please complete the following:
  • What is the purpose of this motivation for LIPTRUZET?*
  • What dosage of LIPTRUZET are you motivating for?*
  • Why are you motivating for LIPTRUZET?*
  • Which of the following applies to your patient?*
  • Applicable ICD 10 code*
  • What is the primary diagnosis for the patient?*
  • Has the patient been on maximum statin therapy for more than two months?*
  • What is the current maximum statin therapy?*
  • Is the patient statin-naive?*
  • What is the current statin therapy?*
  • Is the patient intolerant to high dose statin therapy?*
  • Which of the following reasons best describes why statin up-titration to maximum dose is clinically inappropriate for this patient? (Select any / all relevant)
  • Does the patient have any of the following comorbidities? (please select all that apply)*
  • Does the patient have any of the following risk factors? (please select all that apply)*
  • Relevant family history (please select all that apply)*
  • What is the patient’s cardiovascular risk classification?*

  • Very high risk

    Target LDL-C is
    < 1.8mmol/L and reduction of at least 50% if baseline is
    1.8 - 3.5 mmol/L
    • Genetic dyslipidaemia with total cholesterol > 7.5 mmol/L and/or LDL cholesterol > 5 mmol/L
    • Type 2 diabetes plus one or more other risk factors (smoking, hypertension, dyslipidaemia) or age > 40 years
    • Type 1 diabetes with micro-albuminuria or proteinuria
    • Established atherosclerotic disease (coronary artery disease, cerebrovascular disease, peripheral arterial disease)
    • Severe chronic kidney disease (GFR < 30 ml/min/1.73 m2)
    • Asymptomatic individuals with arterial plaque demonstrated on imaging modalities

    High risk

    Target LDL-C is
    < 2.5mmol/L and reduction of at least 50% if baseline is
    2.5 - 5.2 mmol/L
    • Hypertension - markedly elevated BP (systolic ≥ 180 mmHg and/or diastolic ≥ 110 mmHg)
    • Uncomplicated type 1 or type 2 diabetes (age < 40 without other risk factors)
    • Chronic kidney disease (GFR 30-59 mmol/min/1.73 m2)
  • Date of most recent lipogram? (not older than 3 months)*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Most recent lipogram results:

  • Recommended target LDL-C for this patient:*
  • Which of the following has the patient been treated with previously?*
  • Side effects from previous statin therapy?*
  • Select any/all of the applicable clinical data option/s below for LIPTRUZET 10/10 (ezetimibe 10mg/ atorvastatin 10mg) as part of your motivation:
  • Select any/all of the applicable clinical data option/s below for LIPTRUZET 10/20 (ezetimibe 10mg/ atorvastatin 20mg) as part of your motivation:
  • Select the applicable option/s below for LIPTRUZET 10/40 (ezetimibe 10mg/ atorvastatin 40mg):

  • Supporting documentation

    Please remember to include a copy of the patient’s latest lipogram with your motivation letter.

  • The following documentation will accompany your motivation letter. Please remember to attach the relevant documents to your submission to the funder:

    • LIPTRUZET PI
    • South African dyslipidaemia guideline consensus statement: 2018 update
    • Ballantyne CM, Houri J, Notarbartolo A, et al. Effect of Ezetimibe Coadministered With Atorvastatin in 628 Patients With Primary Hypercholesterolemia. A Prospective, Randomized, Double-Blind Trial. Circulation. 2003;107:2409-2415.
    • Bays HE, Averna M, Majul C, et al. Efficacy and safety of ezetimibe added to atorvastatin versus atorvastatin uptitration or switching to rosuvastatin in patients with primary hypercholesterolemia. Am J Cardiol. 2013;112(12):1885-1895.
    • Stein E, Stender S, Mata P, et al. Achieving lipoprotein goals in patients at high risk with severe hypercholesterolemia: efficacy and safety of ezetimibe co-administered with atorvastatin. Am Heart J. 2004;148(3):447-455.

  • The following documentation will accompany your motivation letter. Please remember to attach the relevant documents to your submission to the funder:

    • LIPTRUZET PI
    • South African dyslipidaemia guideline consensus statement: 2018 update
    • Conard SE, Bays HE, Leiter LA, et al. Efficacy and safety of ezetimibe added on to atorvastatin (20 mg) versus uptitration of atorvastatin (to 40 mg) in hypercholesterolemic patients at moderately high risk for coronary heart disease. Am J Cardiol. 2008;102(11):1489-1494.
    • Bays HE, Averna M, Majul C, et al. Efficacy and safety of ezetimibe added to atorvastatin versus atorvastatin uptitration or switching to rosuvastatin in patients with primary hypercholesterolemia. Am J Cardiol. 2013;112(12):1885-1895.
    • Stein E, Stender S, Mata P, et al. Achieving lipoprotein goals in patients at high risk with severe hypercholesterolemia: efficacy and safety of ezetimibe co-administered with atorvastatin. Am Heart J. 2004;148(3):447-455.

  • The following documentation will accompany your motivation letter. Please remember to attach the relevant documents to your submission to the funder:

    • LIPTRUZET PI
    • South African dyslipidaemia guideline consensus statement: 2018 update
    • Leiter LA, Bays H, Conard S, et al. Efficacy and safety of ezetimibe added on to atorvastatin (40 mg) compared with uptitration of atorvastatin (to 80 mg) in hypercholesterolemic patients at high risk of coronary heart disease. Am J Cardiol. 2008;102(11):1495-1501.
    • Stein E, Stender S, Mata P, et al. Achieving lipoprotein goals in patients at high risk with severe hypercholesterolemia: efficacy and safety of ezetimibe co-administered with atorvastatin. Am Heart J. 2004;148(3):447-455.
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