Health Net
Praluent (alirocumab)
Drugs for the Heart : Drugs for Cholesterol
  • Step Therapy Applies
  • Prior Authorization: ASCVD, HeFH:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: >= 18
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    HoFH:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Quantity Limit: QL=1 pen PER 2 weeks.
  • 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: 6 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: <= 30 day(s)
    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: 6 Month(s)
    Specialist Required: Yes
    Required Medical Information: 2 of Genetic confirmation of mutation in LDL receptor;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: = 1 plan year
    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: Yes
    Documentation Period of LDL-C Levels: <= 60 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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