- Step Therapy Applies
- Prior Authorization: Duration: 6 Month(s)
- 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
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