April 17, 2020
VDP will revise the clinical prior authorization criteria for protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors on July 7. 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)
Refer to the PCSK9 Inhibitor clinical prior authorization criteria guide (PDF) for more information.
- Providers must use the PCSK9 Inhibitors Authorization Request (HHS Form 1354) for fee-for-service Medicaid prior authorization.
- This prior authorization is optional for Medicaid managed care. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each MCO uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. Providers can also refer to the MCO Resources for links to each MCO's list of clinical prior authorizations.
Send questions about this change to email@example.com.