Praluent® (alirocumab)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Praluent authorization criteria

Priority Health authorizes the PCSK9 drug class (Praluent® and Repatha®) when used for homozygous and heterozygous familial hypercholesterolemia

A patient must meet Priority Health prior authorization criteria before coverage is provided.

Not authorized for:

  • Diagnoses of clinical atherosclerotic cardiovascular disease and other conditions
  • Patients without familial hypercholesterolemia
  • Medicaid and Healthy Michigan Plan members

Authorization denials automatically refer your patients to a clinic

When your request for a PCSK9 inhibitor authorization is denied, it triggers a denial letter to the patient which also offers a referral to a Lipid Management Clinic. We also call the member to offer this referral. We notify you when we make this offer to your patient.

If we call and/or write or email your patient about the option of visiting a Lipid Management Clinic:

  • We provide your patient with a list of clinics.
  • We suggest a virtual visit with the Spectrum Health Grand Rapids clinic if they live too far from a physical clinic.

Once your patient lets us know their preference, Priority Health will make a referral, faxing or emailing the patient's information and history to the clinic.