• Copellor Reimbursement Appeal Form

  • Welcome to the Copellor (Ixekizumab) motivation form.

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

    It is not intended to substitute independent medical judgement and approval is not guaranteed by Essential Medical Guidance (EMGuidance) or Aspen. It is designed to remind healthcare professionals (HCPs) of all the information necessary for your application.

    Copellor is indicated for:

    • Plaque psoriasis
      COPELLOR is indicated for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy.
    • Paediatric plaque psoriasis
      COPELLOR is indicated for the treatment of moderate to severe plaque psoriasis in children from the age of 6 years and above with a body weight > 50 kg who are candidates for systemic therapy.
    • Psoriatic arthritis
      COPELLOR, alone or in combination with methotrexate, is indicated for the treatment of active psoriatic arthritis in adult patients who have responded inadequately to, or who are intolerant to one or more disease-modifying anti-rheumatic drug (DMARD) therapies.
    • Axial spondyloarthritis
      Ankylosing spondylitis (radiographic axial spondyloarthritis)
      COPELLOR is indicated for the treatment of adult patients with active ankylosing spondylitis who have responded inadequately to conventional therapy.
    • Non-radiographic axial spondyloarthritis
      COPELLOR is indicated for the treatment of adult patients with active non-radiographic axial spondyloarthritis with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI) who have responded inadequately to nonsteroidal anti-inflammatory drugs (NSAIDs).

    [S4] COPELLOR®, 80 mg/ml, solution for injection. Reg. No.: 50/30.1/0958. Each 1 ml solution contains 80 mg ixekizumab (80 mg/ml). For full prescribing information refer to the professional information as approved by the medicines regulatory authority (12/2021). COPELLOR® is a registered trademark owned or licensed by Eli Lilly and Company, its subsidiaries, or affiliates. © 2024 Aspen Group of Companies or its licensor. 

    All rights reserved. For adverse events reporting, contact: ade_za@lilly.com. For product or medical related queries, contact: za_medinfo@lilly.com

    HCR: Eli Lilly (S.A.) (Pty) Ltd. Reg. No.: 1957/000371. 35 Ballyclare Drive, Bryanston, 2191. Private Bag X119, Bryanston, 2021. Telephone: (011) 510 9300. Marketed and distributed by Pharmacare Limited t/a Aspen Pharmacare. Co. Reg. No. 1898/000252/06 Healthcare Park, Woodlands Drive, Woodmead, 2191

    PP-IX-ZA-0290

  • If you would like to enroll onto the Aspen Immunology Patient Support program, please contact your regional sales representative to facilitate the onboarding of your patient.

  • Today's date
     - -
    2 digit day, 2 digit month, 4 digit year

  • Eligibility Criteria

  • Does the patient have any of the following conditions?*

  • Based on the information you have provided, Copellor is contraindicated for your patient. If you suspect your patient has had an adverse event, report to ade_za@lilly.com. 

    For adverse event reporting, contact: ade_za@lilly.com. For Lilly product complaints and related queries, contact: Medinfo_UKHUB@lilly.com. For Lilly product or medical related queries, contact: za_medinfo@lilly.com 

  • Based on the information you have provided, Copellor is contraindicated for your patient. Should you need more information, please contact Aspen at za_medinfo@lilly.com.

  • Based on the information you have provided, please ensure the patient’s Tuberculosis infection is treated before commencing treatment with Copellor. See Copellor PI

  • Based on the information you have provided, the Copellor Professional Information leaflet recommends proceeding with caution if your patient has an active infection or is HIV positive. See Copellor PI

  • Based on the information you have provided, the Copellor Professional Information leaflet indicates that Ixekizumab is not recommended in patients with inflammatory bowel disease. If a patient develops signs and symptoms of inflammatory bowel disease or experiences an exacerbation of pre-existing inflammatory bowel disease, ixekizumab should be discontinued and appropriate medical management should be initiated. See Copellor PI

  • 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 date of birth*
     - -
    2 digit day, 2 digit month, 4 digit year

  • Based on the information you have provided, Copellor (Ixekizumab) is contraindicated for your patient. Should you need more information, please contact Aspen at za_medinfo@lilly.com

  • Based on the information you have provided, Copellor (Ixekizumab) is contraindicated for your patient. Should you need more information, please contact Aspen at za_medinfo@lilly.com

  • 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:
  • Date of diagnosis*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Psoriasis Area and Severity Index (PASI)*
  • Severity classification: Would you like to include scores or indicate additional domains affected*
  • Skin/Difficulty to treat areas*
  • Presence of Dactylitis*
  • Presence of Enthesitis*
  • Presence of Extra-articular disease*

  • Medical History

    As part of your motivation details please complete the following:
  • What is the patient currently being treated with?*
  • What is the csDMARD* combination (Select all which apply)*

  • *Conventional Synthetic Disease Modifying Anti-Rheumatic Drug

  • Please indicate which of the following treatments the patient has received:*
    Rows
  • What imaging or Lab findings were done to support the diagnosis*

  • Please remember to attach a copy of the patient’s X-Rays when submitting the Motivation Assistance letter to the Medical Aid.

  • Please remember to attach a copy of the patient’s MRI findings when submitting the Motivation Assistance letter to the Medical Aid.

  • Please remember to attach a copy of the patient’s CT Scan when submitting the Motivation Assistance letter to the Medical Aid.

  • Please remember to attach a copy of the patient’s Ultrasound when submitting the Motivation Assistance letter to the Medical Aid.

  • Please select from the lab tests below*

  • Please remember to attach a copy of the patient’s lab results (FBC) when submitting the Motivation Assistance letter to the Medical Aid.

  • The RF Factor was:*
  • The HLA-B27 was:*
  • Does the patient have any of the following comorbid conditions (please select all that are relevant)*
  • Funder suggestion of alternative therapy*

  • Supportive Documentation

    You will be supplied with the following documents along with the motivation letter
    • SARAA Guidelines (Management of peripheral spondyloarthritis)
    • Copellor PI
    • Copellor PIL 
  • Should be Empty: