| Anthem Blue Cross (HMO, PPO, EPO) |
| Nexlizet (bempedoic acid-ezetimibe) |
| Drugs for the Heart : Drugs for Cholesterol |
- Quantity Limit: 1 tablet per 1 day(s).
- PA Applies
- ASCVD:
Duration: 1 year(s)
Required Medical Information: History of CVD or ASCVD
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
ASCVD - Pooled Cohort Risk Assessment: N/A
Baseline LDL-C Level to Initiate Therapy (% reduction): <= 50
Baseline LDL-C Level to Initiate Therapy (mgdL): >= 70
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: No
Concomitant therapy required with maximally tolerated statin: No
Documentation Period of LDL-C Levels: N/A
History of CVD presumed to be of Atherosclerotic origin: No
LDL-C Level for Reauthorization (mgdL): Unspecified
LDL-C Level for Reauthorization (% reduction): Unspecified
Lifestyle modifications required: No
Duration of Statin Step Failure: N/A
Duration of Ezetimibe Step Failure: N/A
Ezetimibe Step is Optional: No
LDL-C Goal for Optional Ezetimibe Step (% reduction): N/A
Statin Intolerance Defined: No
PushTronex MUST be used after Syringe or Sureclick: No
HeFH:
Duration: 1 year(s)
Required Medical Information: Genetic confirmation of mutation in LDL receptor
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: Unspecified
Baseline LDL-C Level to Initiate Therapy (% reduction): < 50
Baseline LDL-C Level to Initiate Therapy (mgdL): >= 70
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: No
Concomitant therapy required with maximally tolerated statin: No
Documentation Period of LDL-C Levels: N/A
LDL-C Level for Reauthorization (mgdL): Unspecified
LDL-C Level for Reauthorization (% reduction): Unspecified
Lifestyle modifications required: No
Diagnosis verbiage includes genetic testing ( LDLR, ApoB, PCSK9 or ARH mutations): No
Diagnosis verbiage includes Simon Broome criteria: No
Diagnosis verbiage includes WHODutch Lipid Network Criteria: No
Diagnosis verbiage includes US MEDPED criteria: No
Duration of Statin Step Failure: N/A
Duration of Ezetimibe Step Failure: N/A
Ezetimibe Step is Optional: No
LDL-C Goal for Optional Ezetimibe Step (% reduction): N/A
Statin Intolerance Defined: No
PushTronex MUST be used after Syringe or Sureclick: No
- Step Therapy: ST Multiple Generics
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;- Prior Authorization: Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
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