| Anthem Blue Cross (HMO, PPO, EPO) |
| Roszet (ezetimibe-rosuvastatin) |
| Drugs for the Heart : Drugs for Cholesterol |
- Step Therapy Applies
- PA Applies
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: HoFH:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
- HoFH:
Duration: 1 year(s)
Required Medical Information: History of untreated/pretreated LDL
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis verbiage includes presence of cutaneous or tendon xanthomas before age 10: No
Diagnosis verbiage includes evidence of HeFH in both parents: No
Baseline LDL-C Level to Initiate Therapy (% reduction): N/A
Baseline LDL-C Level to Initiate Therapy (mgdL): Unspecified
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): N/A
LDL-C Level for Reauthorization (% reduction): N/A
Lifestyle modifications required: No
PushTronex MUST be used after Syringe or Sureclick: No
- Quantity Limit: 1 tablet per 1 day(s).
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