Prior Auth Protocol

FDA Approved Indications:

Lipitor is an inhibitor of HMG-CoA reductase (statin) indicated as an adjunct therapy to diet to:

Reduce the risk of myocardial infarction (MI), stroke, revascularization procedures, and angina in patients without coronary heart disease (CHD), but with multiple risk factors
Reduce the risk of MI and stroke in patients with type 2 diabetes without CHD, but with multiple risk factors
Reduce the risk of non-fatal MI, fatal and non-fatal stroke, revascularization procedures, hospitalization for congestive heart failure (CHF), and angina in patients with CHD
Reduce elevated total cholesterol (total-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (apo B), and triglyceride (TG) levels and increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia
Reduce elevated TG in patients with hypertriglyceridemia and primary dysbetalipoproteinemia
Reduce total-C and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH)
Reduce elevated total-C, LDL-C and apo B levels in boys and postmenarchal girls, 10 to 17 years of age, with heterozygous familial hypercholesterolemia after failing an adequate trial of diet therapy

Health Net Approved Indications and Usage Guidelines:

Coverage is Not Authorized For:

Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature

General Information:

This medication is contraindicated in patients with active liver disease; and in woment who are pregnant, or may become pregnant, or are nursing.

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
This field intentionally left blank.	This field intentionally left blank.	This field intentionally left blank.

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Lipitor	10-80 mg PO QD Pediatric dosing (10 to 17 years old): 10-20 mg PO QD	Length of Benefit

Product Availability:

Tablet: 10, 20, 40, 80 mg

References:

Lipitor [Prescribing Information]. NY, NY: Pfizer; March 2015.
Micromedex^R Healthcare Series [Internet Database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed June 18, 2015.
Lipitor. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 18, 2015.