- Step Therapy Applies
- Prior Authorization: ASCVD:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
HeFH:
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 3 Month(s)
Reauthorization Required: Yes
HoFH:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 3 Month(s)
Reauthorization Required: Yes
- ASCVD:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Required Medical Information: 3 of Chart Notes;History of CVD or ASCVD;History of untreated/pretreated LDL
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Cardiologist;Endocrinologist;Lipid Specialist
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 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: No
Concomitant therapy required with maximally tolerated statin: Yes
Documentation Period of LDL-C Levels: <= 30 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: No
Specialist required details: Specialist Consultation
Duration of Statin Step Failure: >= 4 month(s)
Duration of Ezetimibe Step Failure: >= 4 month(s)
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:
Age Requirement: >= 18
Duration: 3 Month(s)
Specialist Required: Yes
Required Medical Information: 2 of Chart Notes;History of untreated/pretreated LDL
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Cardiologist;Endocrinologist;Lipid Specialist
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Baseline LDL-C Level to Initiate Therapy (% reduction): N/A
Baseline LDL-C Level to Initiate Therapy (mgdL): >= 190
Concomitant therapy required with Bile acid sequestrant or niacin: No
Concomitant therapy required with ezetimibe: No
Concomitant therapy required with maximally tolerated statin: Yes
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: Yes
Diagnosis verbiage includes WHODutch Lipid Network Criteria: Yes
Diagnosis verbiage includes US MEDPED criteria: No
Specialist required details: Specialist Consultation
Duration of Statin Step Failure: >= 4 month(s)
Duration of Ezetimibe Step Failure: >= 4 month(s)
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
HoFH:
Duration: 3 Month(s)
Specialist Required: Yes
Required Medical Information: 3 of Chart Notes;Evidence of HeFH in both parents for HoFH;Genetic confirmation of mutation in LDL receptor;History of untreated/pretreated LDL
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Cardiologist;Endocrinologist;Lipid Specialist
Specialty Pharmacy Provider(s): CVS Specialty
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Diagnosis verbiage includes presence of cutaneous or tendon xanthomas before age 10: Yes
Diagnosis verbiage includes evidence of HeFH in both parents: Yes
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: No
Concomitant therapy required with maximally tolerated statin: No
Documentation Period of LDL-C Levels: <= 30 day(s)
LDL-C Level for Reauthorization (mgdL): Unspecified
LDL-C Level for Reauthorization (% reduction): Unspecified
Lifestyle modifications required: No
Specialist required details: Specialist Consultation
PushTronex MUST be used after Syringe or Sureclick: No
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