- Step Therapy Applies
- Prior Authorization: Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 9 Month(s)
Reauthorization Required: Yes
- ASCVD:
Age Requirement: >= 18
Duration: 9 Month(s)
Specialist Required: Yes
Required Medical Information: Medical Test
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Cardiologist;Endocrinologist;Lipid Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 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: <= 60 day(s)
History of CVD presumed to be of Atherosclerotic origin: No
LDL-C Level for Reauthorization (mgdL): N/A
LDL-C Level for Reauthorization (% reduction): N/A
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: 9 Month(s)
Specialist Required: Yes
Required Medical Information: Medical Test
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Cardiologist;Endocrinologist;Lipid Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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: Yes
Documentation Period of LDL-C Levels: <= 60 day(s)
LDL-C Level for Reauthorization (mgdL): N/A
LDL-C Level for Reauthorization (% reduction): N/A
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: 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
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