Video

For tips check out our video on this drug.


Table of Contents

Always Include
Optional
Rarely Needed

Diagnosis

This question will always be asked. Its important to decide which diagnosis you want to go for. 

Cardiovascular Disease

If the patient has preexisting cardiovascular disease, we need to document at least one example. See the right hand list for example of cardiovascular disease.

What to Send

  • What type of cardiovascular disease the patient has.

Examples

  • Acute Coronary Syndromes
  • Angina
  • Coronary Artery Disease
  • Myocardial Infarction
  • Peripheral Vascular Disease
  • Revascularization procedure (e.g. coronary bypass graft) 
  • Stroke
  • Transient Ischemic Attack

Familial Hypercholesterolemia

For FH patient use the MEDPED criteria to qualify the patient's diagnosis. (This is based on total cholesterol, not LDL)

What to Send

  • Starting Total Cholesterol (not LDL)
  • Closest relative who also has FH (e.g. first degree, second degree, etc.)

MEDPED Criteria

Primary Hyperlipidemia

If the patient also has cardiovascular disease or FH, it is better to go that route as it is easier to get covered.

What to Send

  • Statement the patient has primary hyperlipidemia.

Diet Exercise Statement

Some insurers will require some kind of written statement the patient received diet and exercise counseling (e.g. advised low fat diet). 

What to Send

  • Statement the patient was counseled on diet and exercise.

LDL Lab

Documentation of the patients starting and post treatment LDL (if applicable).

What to Send

  • Most recent LDL lab.
  • Starting LDL lab or approximation of what the starting LDL was (if for continuation).

Tips

  • For new patients insurance generally will want the lab taken within 30-90 days of the request.
  • For renewals generally with 6-12 months is acceptable.

Other Drugs

Fairly uncommon. Usually will only be relevant if the patient is unable to use Repatha and must have Praluent specifically.

What to Send

  • Any other drugs tried and failed.

Other Drug Examples

  • Ezetimibe
  • Nexletol
  • Nexlizet
  • Repatha

Statin History

On Statin

We need to know what statin they are currently taking and if it is the maximum dose they can tolerate. 

What to Send

  • Statin currently being taken
  • If not on a "high intensity statin" is this the maximum dose they can take?

EHHOP - Statin Intensity Table

Not On Statin

If not on a statin, we need a specific reason why they are not taking one. Examples include persistent muscle pains (myalgias) or a contraindication (e.g. liver disease).  

What to Send

  • What statins have been tried in the past.
  • Any contraindication or reason they are not using the statin.
  • If for myalgias, statement the lowest dose was tried (if applicable).

Common Statins

  • Atorvastatin
  • Cerivastatin
  • Fluvastatin
  • Lovastatin
  • Pitavastatin
  • Pravastatin
  • Rosuvastatin
  • Simvastatin