CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Nexletol & Nexlizet Prior Authorization Request Form

Prior authorization request form for Nexletol (bempedoic acid) and Nexlizet (bempedoic acid/ezetimibe) capturing required patient, medication, clinical indication (ASCVD or HeFH), prior statin/ezetimibe therapy, LDL-C thresholds, intolerance/contraindication information, and reauthorization criteria. Used by providers to request coverage via OptumRx/BCBS South Carolina.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyNexletol & Nexlizet Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and fax the form to 844-403-1029 or use go.covermymeds.com/OptumRx to initiate the prior authorization request; incomplete information may result in denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported for this update.

2Covered Indications (ASCVD, HeFH)

120 daysLDL-C measurement lookback

12 weeksRequired prior statin/ezetimibe duration

Coverage Summary

This prior authorization request form is used by OptumRx for Nexletol (bempedoic acid) and Nexlizet (bempedoic acid/ezetimibe) for Blue Cross Blue Shield - South Carolina. It covers the indications ASCVD and HeFH and requires documentation of the indication (ASCVD confirmation options or HeFH diagnostic criteria). The form requires at least 12 consecutive weeks of prior statin therapy at a specified intensity (high, moderate, or low) or documentation of statin intolerance/contraindication, and documents whether the patient has had 12 weeks of ezetimibe when required. LDL-C must be measured while on maximally tolerated statin therapy within the prior 120 days and meet thresholds of ≥70 mg/dL with ASCVD or ≥100 mg/dL without ASCVD. Reauthorization expects documentation of a positive clinical response (for example LDL-C reduction) and continuation of other lipid-lowering therapy at maximally tolerated doses, or documentation of inability to take those therapies.

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Initial Authorization — Indications ASCVD or HeFH

Initial Authorization - Indications ASCVD or HeFH

Coverage considered when ALL of the following are met:

ALL of the following

Patient has diagnosis of Atherosclerotic cardiovascular disease (ASCVD) or Heterozygous familial hypercholesterolemia (HeFH).
ASCVD confirmation options listed (e.g., acute coronary syndromes, prior MI, PCI/CABG, PAD, stroke, TIA, stable/unstable angina, clinically significant coronary heart disease by testing).
HeFH diagnostic criteria: For HeFH: diagnosis may be confirmed by untreated/pre-treatment LDL-C > 190 mg/dL (>155 mg/dL if <16 years of age) and/or family history or physical findings consistent with HeFH.
Form includes family history items (early MI in relatives, LDL-C >190 in relatives, familial hypercholesterolemia in relatives, tendinous xanthomata/arcus cornealis) and findings (arcus cornealis before 45, functional LDL/apoB/PCSK9 mutation, tendinous xanthomata).
High-intensity statin requirement: Patient has been receiving at least 12 consecutive weeks of one HIGH-INTENSITY statin therapy and will continue at maximally tolerated dose, OR is unable to tolerate high-intensity statin as evidenced by intolerable and persistent (>2 weeks) symptoms (myalgia or myositis with CK <10x ULN).>= 12 weeks on HIGH-INTENSITY statin
High-intensity examples: atorvastatin 40-80 mg, rosuvastatin 20-40 mg.
Moderate-intensity statin option: If not on high-intensity statin, patient has been receiving at least 12 consecutive weeks of one MODERATE-INTENSITY statin therapy and will continue at maximally tolerated dose.>= 12 weeks on MODERATE-INTENSITY statin
Moderate-intensity examples provided in form.
Low-intensity statin option: If not on moderate-intensity statin, patient has been receiving at least 12 consecutive weeks of one LOW-INTENSITY statin therapy and will continue at maximally tolerated dose.>= 12 weeks on LOW-INTENSITY statin
Low-intensity statin examples provided in form.
statin intolerance options
- Intolerant to statins - symptoms: Patient is unable to tolerate low-, moderate-, or high-intensity statins as evidenced by intolerable and persistent (>2 weeks) symptoms (myalgia or myositis with CK <10x ULN).
- Labeled contraindication: Patient has a labeled contraindication to all statins.
- Rhabdomyolysis history: Patient has experienced rhabdomyolysis or muscle symptoms with statin treatment with CK elevations >10x ULN.
LDL-C threshold: Patient has one of the following LDL-C values while on maximally tolerated statin therapy within the last 120 days: LDL-C >= 70 mg/dL with ASCVD OR LDL-C >= 100 mg/dL without ASCVD.LDL-C >= 70 mg/dL (with ASCVD) OR >= 100 mg/dL (without ASCVD)
Must be measured within last 120 days while on maximally tolerated statin therapy.
Ezetimibe requirement: Patient has been receiving at least 12 consecutive weeks of generic ezetimibe therapy as adjunct to maximally tolerated statin therapy, unless there is history of contraindication or intolerance to ezetimibe.>= 12 weeks on ezetimibe when required
Form asks whether ezetimibe used and whether contraindication/intolerance exists.

Provider Actions / Prior Authorization Steps

Prior Authorization

Submit completed Nexletol/Nexlizet prior authorization form

Providers must complete and fax the form (including patient, provider, medication, and all clinical checkboxes) to 844-403-1029 or use go.covermymeds.com/OptumRx to initiate the request; incomplete information may result in denial.

Fax: 844-403-1029
Online: go.covermymeds.com/OptumRx

Documentation Required

Provide evidence of prior lipid-lowering therapy and LDL-C results

Document at least 12 weeks of prior statin therapy at the specified intensity (high, moderate, or low) or evidence of statin intolerance/contraindication; document at least 12 weeks of ezetimibe when required; and provide an LDL‑C value measured while on maximally tolerated statin therapy within the last 120 days.

≥ 12 consecutive weeks of specified statin therapy at the indicated intensity (or documented intolerance/contraindication)
≥ 12 consecutive weeks of generic ezetimibe as adjunct when required (unless ezetimibe intolerance/contraindication documented)
LDL‑C measured within the last 120 days while on maximally tolerated statin therapy

Denial Risk

Risk of denial for incomplete information

Request may be denied unless all required information is received; prescriber signature and date are required.

Prescriber's signature and date are required on the form
Incomplete or missing required information may result in denial

Background

Background: This is an OptumRx prior authorization form for Nexletol and Nexlizet used by BCBS South Carolina. The form captures confirmation of ASCVD (with checklist options such as acute coronary syndromes, prior MI, PCI/CABG, PAD, stroke/TIA, angina, or coronary disease by testing) and documentation supporting HeFH (including untreated/pre-treatment LDL-C >190 mg/dL or family history/physical findings). It records statin intensity and duration requirements (minimum 12 weeks at high, moderate, or low intensity or evidence of intolerance/contraindication), options for statin intolerance or rhabdomyolysis, whether the patient has received 12 weeks of ezetimibe or has ezetimibe intolerance/contraindication, and LDL-C thresholds measured within 120 days. The form also collects reauthorization monitoring information such as documented clinical response (e.g., LDL-C reduction) and continued use of other lipid-lowering therapies at maximally tolerated doses.

Definitions — Statin intensity examples: High-intensity: atorvastatin 40–80 mg, rosuvastatin 20–40 mg. Moderate-intensity: atorvastatin 10–20 mg, rosuvastatin 5–10 mg, simvastatin 20–40 mg, pravastatin 40–80 mg, lovastatin 40 mg, fluvastatin regimens (e.g., Lescol XL 80 mg or 40 mg twice daily), pitavastatin 2–4 mg. Low-intensity: simvastatin 10 mg, pravastatin 10–20 mg, lovastatin 20 mg, fluvastatin 20–40 mg, pitavastatin 1 mg.

OpenPayer

Nexletol & Nexlizet Prior Authorization Request Form

Coverage Summary

Initial Authorization — Indications ASCVD or HeFH

Reauthorization Criteria

Coding

Provider Actions / Prior Authorization Steps

Background

Revision History