Prior Authorization (PA) Form — JUXTAPID (lomitapide)
This document is a PA form used by Anthem HealthKeepers Plus Medicaid (Virginia) to request prior authorization for JUXTAPID (lomitapide) for members; it outlines required member, prescriber, drug, and clinical information to support coverage decisions.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Authorization Criteria
Covered when ALL of the following are met
One completed PA form per member; incomplete forms may delay the PA process and submission of documentation does not guarantee coverage.
The PA form does not include additional general coverage statements beyond the listed authorization criteria. Approval is contingent on meeting the specific items on the form, which require confirmation of diagnosis, age, prior therapy history, documentation of previous medications, and prescriber attestation. The form also notes that incomplete submissions may delay the prior authorization process and that submission of documentation does not guarantee coverage.
The form does not present a separate list of conditions that are explicitly labeled as not medically necessary. However, failure to meet the required items on the form (for example, lack of documented HoFH diagnosis, not meeting the age ≥18 years threshold, or insufficient documentation of prior treatment failure/maximum tolerated dosing or contraindications) may result in denial of the prior authorization.
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