HealthRX.com · Printable cost worksheet
Repatha (evolocumab) cost and coverage worksheet
Use this sheet before calling your pharmacy or insurance plan about the cost of Repatha. It helps you record the exact prescription, ask about biosimilar and copy options, and track the price and coverage answers you receive.
Prescription details
Copy these from your prescription label and insurance card.
Form on prescriptionPen, autoinjector or syringe
Before you call
- Write the full medicine name exactly as it appears on the label
- Bring your insurance card and any recent coverage letter
- List the pharmacy you usually use and its phone number
- Note any prior authorization or plan denial letters you have received
- Confirm whether your plan has changed since your last refill
- Check with your prescriber whether another form is an option
Questions for your pharmacist or insurer
- Is there a compounded version of this medicine that my plan would cover?
- Does my plan cover the original product under its brand name?
- Is there a biosimilar or interchangeable version available for my prescription?
- What is my out-of-pocket cost for one refill under my current plan?
- Does my plan require prior authorization, and what forms do you need?
- What options exist if my cost changes at the start of a new plan year?
- Who can I contact to appeal a coverage decision?
Cost and coverage tracking
Record each call, quote and answer so you can compare them later.
| Date | Who you spoke with | Price or quote | Coverage answer |
|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.