- Step Therapy Applies
- HoFH:
Duration: 6 Month(s)
Specialist Required: Yes
Required Medical Information: 3 of ApoB level;ARH adaptor protein gene locus;Chart Notes;Evidence of HeFH in both parents for HoFH;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: <= 12 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): > 100
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): 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
- Prior Authorization: HoFH:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
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