ASCVD:
Duration: 12 Month(s)
Required Medical Information: 3 of History of CVD or ASCVD;Lab Results;Medication History
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;BriovaRx
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: <= 120 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: Yes
Duration of Statin Step Failure: >= 12 week(s)
Duration of Ezetimibe Step Failure: >= 12 week(s)
Ezetimibe Step is Optional: Yes
LDL-C Goal for Optional Ezetimibe Step (% reduction): N/A
Statin Intolerance Defined: Yes
PushTronex MUST be used after Syringe or Sureclick: No

HeFH:
Duration: 12 Month(s)
Required Medical Information: 4 of Genetic confirmation of mutation in LDL receptor;History of untreated/pretreated LDL;Lab Results;Medication History
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;BriovaRx
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: <= 120 day(s)
LDL-C Level for Reauthorization (mgdL): Unspecified
LDL-C Level for Reauthorization (% reduction): Unspecified
Lifestyle modifications required: Yes
Diagnosis verbiage includes genetic testing ( LDLR, ApoB, PCSK9 or ARH mutations): Yes
Diagnosis verbiage includes Simon Broome criteria: No
Diagnosis verbiage includes WHODutch Lipid Network Criteria: No
Diagnosis verbiage includes US MEDPED criteria: No
Duration of Statin Step Failure: >= 12 week(s)
Duration of Ezetimibe Step Failure: >= 12 week(s)
Ezetimibe Step is Optional: Yes
LDL-C Goal for Optional Ezetimibe Step (% reduction): N/A
Statin Intolerance Defined: Yes
PushTronex MUST be used after Syringe or Sureclick: No

HoFH:
Duration: 12 Month(s)
Required Medical Information: 2 of Evidence of HeFH in both parents for HoFH;History of untreated/pretreated LDL;Lab Results
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;BriovaRx
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): N/A
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: Yes
PushTronex MUST be used after Syringe or Sureclick: No