CurrentAvMedPolicy N/A

Pharmacy prior authorization / step-edit request for pitavastatin

Form and clinical criteria governing prior authorization or step-edit approval for pitavastatin (Livalo®, Zypitamag®) prescribing to AvMed members; applies to prescribers submitting pharmacy PA requests.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization / step-edit request for pitavastatin

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and fax the completed PA form with required documentation to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1drug class covered (pitavastatin products listed)

30 daysrequired trial duration

1prior agents required to fail

faxsubmission fax

Coverage Criteria

Initial Authorization Criteria

Covered when ALL of the following are met

Step therapy and documentation: Member failed to reach LDL-cholesterol goals with a trial of ONE of the following: pravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, or ezetimibe-simvastatin for 30 days (verified by chart notes or pharmacy paid claims).30 days

To support each line checked, all documentation, including lab results, diagnostics, and/or chart notes, must be provided; use of samples to initiate therapy does not meet step edit/preauthorization criteria; previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Use of manufacturer or pharmacy samples to initiate therapy does not satisfy the step-edit / prior authorization requirements for pitavastatin. Samples are not acceptable evidence of a prior trial when verifying failure of alternative statin therapy; prior therapies must be documented via pharmacy paid claims or submitted chart notes to meet the step therapy criteria.

Coding and Trials

Diagnosis code fieldICD-10

ICD Code (field)

ICD code, if applicable (member diagnosis)

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization / step-edit request for pitavastatin

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and fax the completed PA form with required documentation to 1-305-671-0200.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-04: Required trial duration

Required trial duration30 days

Verification methodVerified by chart notes or pharmacy paid claims

Agents acceptable for trialPravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, or ezetimibe-simvastatin

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization and/or step therapy is required for pitavastatin (Livalo®) and Zypitamag® (pitavastatin). The prescribing physician must sign and print their name on the request form (preprinted stamps are not valid). Fax completed forms to 1-305-671-0200. Incomplete, incorrect, or illegible information (including missing phone/fax numbers) can delay or result in denial of authorization.

Drug requested: pitavastatin (Livalo®) or Zypitamag® (pitavastatin)
Fax number: 1-305-671-0200
Prescriber signature and printed name required (stamps not valid)

Step Therapy

Step Therapy Failure Required

Member must have failed to reach LDL-cholesterol goals after a trial of ONE listed agent for at least 30 days. Acceptable agents include pravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, or ezetimibe-simvastatin. Failure must be verified by chart notes or pharmacy paid claims.

Required trial: ONE agent for ≥30 days (pravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, or ezetimibe-simvastatin)
Verification: chart notes or pharmacy paid claims

Documentation Required

Supporting Documentation Required

Provide supporting documentation for each clinical criterion checked. Documentation may include laboratory results (e.g., LDL values), diagnostics, clinic chart notes, and prior therapy verification (pharmacy paid claims). Use of samples to initiate therapy does not satisfy step-edit/preauthorization requirements.

Include lab results, diagnostics, and chart notes supporting LDL goal failure
Prior therapies will be verified via pharmacy paid claims or submitted chart notes
Samples do not meet step-edit/preauthorization criteria

Documentation Required

Form Completion and Signature

Prescribing physician must sign and print their name on the form (preprinted stamps not valid). Include member identifiers (Member name, AvMed #, DOB), prescriber contact name, phone and fax numbers, and DEA or NPI number. Authorization may be delayed if member or prescriber information is incomplete.

Prescriber signature and printed name required
Include Member name, AvMed #, Date of Birth
Include office contact, phone, fax, and DEA or NPI #

Denial Risk

Incomplete Documentation or Missing Prior Therapy Verification May Delay or Deny

Authorizations can be delayed or denied if the form is incomplete, incorrect, illegible, or missing required supporting documentation (labs, diagnostics, chart notes, prior therapy verification). Ensure all requested fields are completed to avoid processing delays.

Incomplete/incorrect/illegible form information may delay or deny authorization
Missing supporting documentation may result in denial

Background

Pitavastatin is an HMG-CoA reductase inhibitor (a statin) used to lower LDL-cholesterol. Coverage under this policy is subject to a step therapy requirement: the member must have failed to reach LDL-cholesterol goals after a trial of one listed alternative agent (pravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, or ezetimibe-simvastatin) for 30 days, verified by chart notes or pharmacy paid claims, and all supporting documentation (labs, diagnostics, chart notes) must be submitted with the request.

Definitions

inv-11: Failed therapy

DefinitionFailure to reach LDL-cholesterol goals

Context for failureMember must have failed to reach LDL-cholesterol goals after a 30-day trial of one listed statin or ezetimibe-simvastatin

Documentation requiredSupporting documentation (lab results, diagnostics, and/or chart notes) must be provided for each checked criterion

Samples policyUse of samples to initiate therapy does not meet step edit/preauthorization criteria

Initial Therapy Criteria

Initial therapy requirement

Initial coverage requires prior trial failure

Prior statin/ezetimibe-statin trial: Member must have failed to reach LDL-cholesterol goals with a trial of ONE of: pravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, or ezetimibe-simvastatin for 30 days (verified by chart notes or pharmacy paid claims).30 days

Use of samples to initiate therapy does not count; prior therapies will be verified through pharmacy paid claims or submitted chart notes.

Step Therapy Requirements

Step	Requirement	Verification
1
Member must have failed to reach LDL-cholesterol goals with a trial of ONE of: pravastatin, atorvastatin, rosuvastatin, fluvastatin, simvastatin, or ezetimibe-simvastatin
30-day trial verified by chart notes or pharmacy paid claims; samples do not count