PCSK9 Clinical Prior Authorization Criteria Changes To Begin May 22, 2020

PCSK9 Clinical Prior Authorization Criteria Changes To Begin May 22, 2020

FirstCare will revise the clinical prior authorization criteria for protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors on May 22, 2020. All clinical edit criteria can be found here.

Revisions include:

• The LDL requirement for initiation of PCSK9 therapy was changed from greater than or equal to 130 mg/dL to greater than or equal to 70mg/dL
• Diagnosis of Heterozygous Familial Hypercholesterolemia) (HeFH) was replaced with the diagnosis of Primary Hyperlipidemia which includes HeFH diagnosis
• The list of generic code numbers for atorvastatin and rosuvastatin was updated (Table 5)
• References