CurrentAvMedPolicy N/A

Ezetimibe‑simvastatin (Vytorin) prior authorization

Defines pharmacy prior authorization requirements and clinical criteria for coverage of ezetimibe-simvastatin (Vytorin) for AvMed members; applies to prescribing providers submitting PA for this combination product.

Policy Summary

PayerAvMed

PolicyEzetimibe‑simvastatin (Vytorin) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed AvMed PA form with documentation of two failed statin trials or 12 weeks on maximally tolerated statin plus lipid panel and chart notes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2required prior statin trials

12min duration (weeks)

1recommended daily tablet

1-305-671-0200PA submission fax

Coverage Criteria

inv-01: Initial Authorization

Covered when ALL of the following are met

Main criteria

Statin trials or maximally tolerated therapy: Member has tried and failed TWO of the listed statins, OR statin therapy at maximally tolerated dose for at least 12 consecutive weeks and did NOT achieve LDL cholesterol goal (verification via chart notes or pharmacy paid claims).2
List of statins provided on form (select applicable agents and doses).
Lipid panel evidence: Provider has submitted results of member's lipid panel showing further reduction in LDL cholesterol is required despite compliant use of maximally tolerated statin monotherapy; current LDL-C and LDL-C goal must be provided.lab results
Fields on form: Current LDL-C and LDL-C Goal.

Policy Summary

PayerAvMed

PolicyEzetimibe‑simvastatin (Vytorin) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a signed AvMed PA form with documentation of two failed statin trials or 12 weeks on maximally tolerated statin plus lipid panel and chart notes.

SourceLink

On This Page

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Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Submission

Prior authorization is required for ezetimibe-simvastatin (Vytorin). Submit a completed AvMed Pharmacy Prior Authorization form via fax to 1-305-671-0200. The prescribing physician must hand-sign and clearly print their name on the request (preprinted stamps are not valid). Ensure phone and fax numbers and all contact fields are complete and legible to avoid processing delays.

Fax PA form to 1-305-671-0200
Prescriber handwritten signature required (preprinted stamps not valid)
Include office contact name, phone and fax numbers, and NPI

Denial Risk

Clinical Criteria Not Met

All clinical criteria must be met for approval. If the member has not tried and failed TWO specified statins or has not been on maximally tolerated statin therapy for at least 12 consecutive weeks (with documentation that LDL goal was not achieved), the request may be denied.

Approval requires documentation that member tried and failed two listed statins OR statin therapy at maximally tolerated dose ≥12 weeks without achieving LDL goal
Previous therapies may be verified via pharmacy paid claims

Documentation Required

Required Supporting Documentation

Provide supporting documentation for each checked clinical criterion. Incomplete or missing documentation (lab results, diagnostics, or chart notes) can delay review or result in denial.

Attach lipid panel with current LDL-C and LDL-C goal
Provide chart notes documenting medication trials, tolerability, and clinical rationale
Include pharmacy paid-claim history if available to verify prior therapies
Samples used to initiate therapy do NOT meet step-edit/preauthorization criteria

Note

Prescriber and Member Information

Complete member and prescriber information on the PA form. Authorization may be delayed if these fields are incomplete or illegible.

Member name, AvMed ID, and date of birth
Prescriber name, handwritten signature, and date
Office contact name, phone number, fax number, and NPI

Denial Risk

Form Completeness and Signature

Incomplete, incorrect, or illegible information (including missing prescriber signature) on the PA form or failure to submit required supporting documentation may delay processing or cause denial of the request.

Illegible or missing fields can delay authorization
All checked clinical criteria must have accompanying documentation or request may be denied

Initial Therapy Criteria

inv-13: Initial therapy

Initial authorization requirements

Initial therapy requirements

Statin trial specifics: Select and document TWO tried and failed statins from the form (agents and doses listed such as atorvastatin, simvastatin, rosuvastatin, pravastatin, lovastatin, fluvastatin).2 statins
Use the checkboxes on the form to indicate which statins and doses were tried.
Duration of maximally tolerated statin: If claiming maximally tolerated statin therapy instead of two failed statins, therapy must have been at maximally tolerated dose for at least 12 consecutive weeks without achieving LDL goal.>= 12 consecutive weeks
Verification via chart notes or pharmacy paid claims.
Laboratory evidence: Submit current LDL-C and LDL-C goal from a recent lipid panel to demonstrate need for additional LDL lowering.lab results
Provide values in the Current LDL-C and LDL-C Goal fields on the form.
Inadequate response to concomitant ezetimibe: Document that member tried concomitant statin plus ezetimibe and had an inadequate response (acceptable alternative to failing two statins).documented inadequate response
Indicate prior concomitant therapy on form and provide supporting chart notes or labs.
Clinical rationale if convenience: If the request could be viewed as convenience, submit chart notes documenting why the combination product is medically necessary rather than for convenience.chart notes
Chart documentation required to justify medical necessity.

Step Therapy and Documentation Table

Requirement	Documentation needed
Member has tried and failed TWO of the listed statins OR statin therapy at maximally tolerated dose for at least 12 consecutive weeks without achieving LDL goal	Checkboxes on PA form indicating which statins were tried; chart notes or pharmacy paid claims verifying trials and duration
Provider has submitted results of member's lipid panel showing current LDL-C and LDL-C goal demonstrating need for further LDL reduction	Lipid panel results with Current LDL-C and LDL-C Goal fields completed on PA form
Member has tried concomitant statin plus ezetimibe with inadequate response (alternative to two statin failures)	Documentation of inadequate response (chart notes or prior therapy records)
Provider has submitted chart notes documenting clinical rationale that combination therapy is medically necessary and not for convenience	Chart notes detailing clinical rationale
Use of samples to initiate therapy does not meet step edit/preauthorization criteria	N/A — samples are not acceptable documentation for initiation

OpenPayer

Ezetimibe‑simvastatin (Vytorin) prior authorization

Coverage Criteria

Coding and Coding-related Criteria

Provider Actions and Submission Requirements

Background

Definitions and Dosing

Initial Therapy Criteria

Step Therapy and Documentation Table