ASCVD:
Duration: 12 Month(s)
Specialist Required: Yes
Required Medical Information: 3 of Chart Notes;History of CVD or ASCVD;History of untreated/pretreated LDL;Medication History
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Cardiologist;Endocrinologist;Lipid Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
ASCVD - Pooled Cohort Risk Assessment: N/A
Baseline LDL-C Level to Initiate Therapy (% reduction): N/A
Baseline LDL-C Level to Initiate Therapy (mgdL): >= 70
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: Yes
Concomitant therapy required with maximally tolerated statin: Yes
Documentation Period of LDL-C Levels: <= 120 day(s)
History of CVD presumed to be of Atherosclerotic origin: Yes
LDL-C Level for Reauthorization (mgdL): Unspecified
LDL-C Level for Reauthorization (% reduction): Unspecified
Lifestyle modifications required: Yes
Specialist required details: Specialist Approval
Duration of Statin Step Failure: >= 12 week(s)
Duration of Ezetimibe Step Failure: >= 12 week(s)
Ezetimibe Step is Optional: Yes
LDL-C Goal for Optional Ezetimibe Step (% reduction): N/A
Statin Intolerance Defined: Yes
PushTronex MUST be used after Syringe or Sureclick: No

HeFH:
Duration: 12 Month(s)
Required Medical Information: 2 of Chart Notes;Genetic confirmation of mutation in LDL receptor;History of untreated/pretreated LDL
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Baseline LDL-C Level to Initiate Therapy (% reduction): N/A
Baseline LDL-C Level to Initiate Therapy (mgdL): >= 70
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: Yes
Concomitant therapy required with maximally tolerated statin: Yes
Documentation Period of LDL-C Levels: <= 12 week(s)
LDL-C Level for Reauthorization (mgdL): Unspecified
LDL-C Level for Reauthorization (% reduction): Unspecified
Lifestyle modifications required: Yes
Diagnosis verbiage includes genetic testing ( LDLR, ApoB, PCSK9 or ARH mutations): Yes
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: >= 12 week(s)
Duration of Ezetimibe Step Failure: >= 12 week(s)
Ezetimibe Step is Optional: Yes
LDL-C Goal for Optional Ezetimibe Step (% reduction): N/A
Statin Intolerance Defined: Yes
PushTronex MUST be used after Syringe or Sureclick: No