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Why Repatha Requires Prior Authorization and How to Succeed?

If you’ve handled prior authorizations for medications like Repatha (evolocumab), you know it can be a challenging process. As a healthcare provider, you’re juggling countless responsibilities—caring for patients, managing staff, and keeping up with clinical advancements. Adding complex insurance requirements for high-cost medications like Repatha to the mix can feel overwhelming.
The silver lining? A methodical approach, clear documentation, and reliable support can make the process much smoother. In this guide, we’ll break down every step to help you secure prior authorization for Repatha.

Understanding Insurance Company Policies

Insurance carriers like UnitedHealthcare, Aetna, Cigna, and Blue Cross Blue Shield differentiate Repatha coverage based on whether it’s classified as Pharmacy Benefits or Medical Benefits. When determining coverage, insurers should consider Repatha’s inclusion in their formulary, if step therapy requirements apply, and if submission is via a portal like CoverMyMeds or their proprietary system.

Why Do Insurers Require Prior Authorization for Repatha?

Repatha is a PCSK9 inhibitor designed for patients with conditions like familial hypercholesterolemia and atherosclerotic cardiovascular disease. It’s a game-changer due to its high cost and specialty drug status, necessitating strict approval from insurers. To be approved, the patient must meet insurance policy clinical criteria, have tried other affordable therapies unsuccessfully, and the prescription aligns with FDA-approved indications or insurer guidelines.

Step-by-Step Process for Repatha Prior Authorization

Step 1: Gather Essential Documentation

The strength of your submission depends on the quality of your documentation. Before starting, make sure to collect:

• Letter of medical necessity: Detail the patient’s diagnosis, history of treatment failures, and why Repatha is the best choice.
• Patient history: Include lipid panels, genetic testing (if applicable), and other lab results.
• Step therapy documentation: Provide records showing other therapies were ineffective, not tolerated, or contraindicated.
• PA form: Download the specific form required by the insurer from their website or portal.

Step 2: Submit the PA Request

Most insurers prefer electronic submissions via platforms like CoverMyMeds or their proprietary portals.

• Attach all documentation, including the letter of medical necessity and lab results.
• Double-check for completeness and accuracy to avoid rejections.
• Submit through the designated channel (fax, email, or portal) and confirm receipt.

Step 3: Follow Up on Your Submission

After submitting the PA request, monitor its status. Response times vary by insurer but typically range from 5 to 14 business days.

• Contact the insurer to confirm receipt and verify whether additional documentation is needed.
• Stay prepared to provide clarifications or supplementary records if the insurer requests them.

Step 4: Handle Approvals or Denials

If the PA is approved:

• Confirm details like the patient’s copay, duration of coverage, and whether renewal is required.
• Ensure the prescription is sent to the appropriate specialty pharmacy if Repatha is covered under pharmacy benefits.

If the PA is denied:

• Review the denial letter carefully to understand the reason.
• Submit an appeal with additional clinical evidence, lab results, or a more detailed letter of medical necessity.

ICD and CPT Codes Explained

Accurate coding is a cornerstone of prior authorization. Using the wrong codes or mismatched codes can cause delays or even denials. Here’s a quick guide to commonly used codes for Repatha:

ICD-10 Codes

These codes explain the patient’s diagnosis:

• E78.0: Pure hypercholesterolemia
• E78.01: Familial hypercholesterolemia
• I25.10: ASCVD without angina

CPT Codes

These codes document the procedure, particularly if Repatha is administered in-office:

• 96372: Therapeutic, prophylactic, or diagnostic injection (subcutaneous or intramuscular).
• J3490: Unclassified drugs, used when billing for Repatha under medical benefits if no specific HCPCS code is provided.

Frequently Asked Questions (FAQs)

1. Why is prior authorization required for Repatha?
Repatha’s high cost and specialized nature mean insurers require prior approval to ensure it’s necessary and aligns with coverage criteria.

2. What happens if my PA request is denied?
Denials often stem from incomplete documentation or unmet clinical criteria. Submit an appeal with additional evidence to strengthen your case.

3. How can I track my PA request?
Many insurers offer online tracking through platforms like CoverMyMeds or their own portals. Alternatively, call the insurer for updates.

4. How long does it take to get a decision?
Standard requests typically take 5–14 business days, but urgent cases may be expedited.

5. Do I need to renew the PA for Repatha?
Yes, many insurers require periodic reauthorization, often every 6 or 12 months.

What Did We Learn?

• Documentation is essential: Submit thorough, accurate records to minimize delays.
• Precision matters: Ensure ICD-10 and CPT codes align with the patient’s diagnosis and treatment plan.
• Be proactive: Follow up regularly and stay prepared to provide additional information.
• Appeals work: Many denials are overturned with additional evidence or clarification.

Staffingly, Inc. offers a step-by-step approach to managing the process of prior authorization for Repatha, a medication that can be time-consuming for busy healthcare providers. Their expert team handles authorizations, insurance verifications, and appeals, ensuring a smoother experience for healthcare providers. With 70% cost savings, 24/7 support, and a dedicated team, Staffingly provides peace of mind for healthcare providers, allowing them to focus on patient care.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of healthcare processes. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com.