Health Net
Praluent Syringe (alirocumab)
Drugs for the Heart : Drugs for Cholesterol
  • Step Therapy Applies
  • ASCVD:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Documented Diagnosis: No
    Medical Test Required: No
    Specialist Type(s): 1 of Cardiologist;Endocrinologist;Lipid Specialist
    Reauthorization Required: No
    Concomitant therapy required with Bile acid sequestrant or niacin: No
    Concomitant therapy required with ezetimibe: No
    Concomitant therapy required with maximally tolerated statin: No
    History of CVD presumed to be of Atherosclerotic origin: Yes
    Lifestyle modifications required: No
    Specialist required details: Unspecified
    Ezetimibe Step is Optional: No
    Statin Intolerance Defined: No
    PushTronex MUST be used after Syringe or Sureclick: No

    HeFH:
    Duration: 6 Month(s)
    Documented Diagnosis: No
    Medical Test Required: No
    Reauthorization Required: No
    Concomitant therapy required with Bile acid sequestrant or niacin: No
    Concomitant therapy required with ezetimibe: No
    Concomitant therapy required with maximally tolerated statin: No
    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
    Specialist required details: Unspecified
    Ezetimibe Step is Optional: No
    Statin Intolerance Defined: No
    PushTronex MUST be used after Syringe or Sureclick: No

  • Prior Authorization: Duration: 6 Month(s)