Please note that this information is provided as a resource only.

 

The format below is based on what is functional in Epic, including the shortcut functions (*** and {xyz}). These shortcut functions are intended to be fill-in-the-blank if used on another platform. The comments in bracketed italics are common limitations on use, for example, an EF threshold for approval, but are informational only as plans may have different limitations.

General format:
Medication name/dose:
Diagnosis:
Previous therapies:
     {include other current meds, dates, and ADE if known}
[Medication specific requirements]:
Baseline monitoring completed within 30 days: {yes/no}
{medication specific labs with dates}

ANTI-HYPERLIPIDEMICS

Medication name/dose: Praluent {75mg every other week, 150mg every other week, 300mg once monthly}

Diagnosis (with relevant co-morbidities): {mixed hyperlipidemia, pure hyperlipidemia, heterozygous familial hypercholesterolemia (HeFH), statin intolerance, coronary artery disease, peripheral artery disease, ischemic stroke, etc}

Previous therapies:

• {include current and past meds with doses, dates, and ADE if known}

Patient with uncontrolled cholesterol despite current therapy: {yes/no} {typically defined as LDL >70 mg/dL for secondary prevention patients or an LDL >100 or <50% decreased from max for patients with familial hypercholesterolemia}

Baseline monitoring completed within 30 days: {yes/no}

• Lipid panel {date} – LDL ***

---

Medication name/dose: Repatha {140mg every other week, 420mg once monthly} {for 420mg monthly dose, specify if requesting autoinjector (3 syringes per dose) or the on-body infusor}

Diagnosis (with relevant co-morbidities): {mixed hyperlipidemia, pure hyperlipidemia, heterozygous familial hypercholesterolemia (HeFH), homozygous familial hypercholesterolemia (HoFH), statin intolerance, coronary artery disease, peripheral artery disease, ischemic stroke, etc}

Previous therapies:

• {include current and past meds with doses, dates, and ADE if known}

Patient with uncontrolled cholesterol despite current therapy: {yes/no} {typically defined as LDL >70 mg/dL for secondary prevention patients or an LDL >100 or <50% decreased from max for patients with familial hypercholesterolemia}

Baseline monitoring completed within 30 days: {yes/no}

• Lipid panel {date} – LDL ***

---

Medication name/dose: Vascepa {2g twice daily}

Diagnosis (with relevant co-morbidities): {hypertriglyceridemia, mixed dyslipidemia, history of pancreatitis}

Vascepa prescribed based on REDUCE-IT trial: {yes, no}

• If yes: Relevant co-morbidities: {diabetes, myocardial infarction, arterial revascularization, etc}

Previous therapies:

• {include current and past meds with doses, dates, and ADE if known} {include trials of OTC fish oil}

Patient with uncontrolled triglycerides: {yes/no} {typically defined as TRG >500 currently or prior to any use of triglyeride lowering medications, for REDUCE-IT defined as TRG 150-500}

Baseline monitoring completed within 30 days: {yes/no}

• Lipid panel {date} – TRG ***

---

NEPRILYSIN INHIBITORS

Medication name/dose: Entresto {24mg/26mg (pt not currently on ACE-I/ARB) or 49mg/51mg (on ACE-I/ARB)}

Diagnosis: Chronic Heart Failure

• Current NYHA class: {II, III, IV}
• Last LVEF: {% and date} {typically approved for EF <40%}

Previous therapies:

• {include past and current use of ACE-I, ARB, beta blocker, etc. Include doses, dates, and ADE if known} {use is not recommended for patients with h/o angioedema to ACE-I or ARB}
• If patient is currently on an ACE-I or ARB, they have been educated on need for a 36 hour washout period before starting Entresto.

If the patient is a female of child-bearing age, are they currently pregnant?: {yes/no/not applicable} {contraindicated in pregnancy}

Baseline monitoring completed within 30 days: {yes/no}

• Serum creatinine drawn {date}
• Serum potassium drawn {date}

---

OTHER AGENTS

Medication name/dose: Ivabradine (Corlanor) {5mg twice daily (starting dose), 2.5mg twice daily, 7.5mg twice daily}

Diagnosis: Chronic heart failure

• Current NYHA class: {II, III, IV}
• Last LVEF: {% and date} {typically approved for EF <35%}

Previous therapies:

• {include other current meds, dates, and ADE if known} {patient needs to be on maximally tolerated beta blocker OR have failed or be contraindicated to use}

Last EKG demonstrates sinus rhythm with HR >70 bpm: {yes/no}, on {date}, HR ***

Baseline monitoring completed within 30 days: {yes/no}

• Liver function tests drawn {date} {contraindicated for Child-Pugh C}

---

Medication name/dose: {Vyndamax 61mg daily or Vyndaqel 80mg daily}

Diagnosis: Transthyretin related familial amyloid cardiomyopathy, {Wild type or hereditary}

• Diagnosis made based on: {genetic testing {date}, technetium pyrophosphate scan {date}, or  amyloid deposits on cardiac tissue biopsy {date}

Clinical signs and symptoms of disease: {yes/no} {consider including what, ie peripheral neuropathy, cardiovascular dysfunction, renal dysfunction, etc}

Medical history of heart failure or cardiomyopathy: {yes/no}, if yes, {NYHA class ***}

Previous therapies: {include dates, ADE if known} {typically requires additional justification if intended to be used with patisiran, inotersen, or diflunisal}

---

Medication name/dose: Opsumit 10mg daily

Diagnosis: Pulmonary arterial hypertension, WHO Group 1

• Diagnosis confirmed with RHC on {date}. mPAP ***, PCWP ***, and PVR *** {typically requires mPCP >25mmHg, PCWP <15mmHg, and PVR >3 Wood units for approval}

Previous therapies:

• {include other current meds, dates, and ADE if known}

Current heart failure class: {II or III}

Baseline monitoring completed within 30 days: {yes/no}

• If patient is a woman of child-bearing age, negative pregnancy test: {date} {package insert recommends monthly pregnancy test while on therapy and for one month after discontinuation}
• Liver function tests drawn {date}
• Hemoglobin drawn {date}