30 days for three months Renewal: 3 months Crestor can be approved when the following criteria are met: Initial Approval: Hyperlipidemia Patient is at least 10 years old; AND PSCK9 inhibitors: 3 Medications months Patient has failed to achieve LDL goal on a compliant regimen of maximum tolerated dose Last reviewed: 6/15/15 Juxtapid, Kynamro: 3 of atorvastatin; OR months Crestor Patient requires a high intensity statin (i.e., diagnosis of familial hypercholesterolemia or All others: 6 months high ASCVD risk per provider evaluation) AND patient had a trial and failure of atorvastatin Zetia Renewal: requires step therapy: inhibitors: 6 months Lovaza If member has filled 2 prescriptions for 2 different statins (specifically atorvastatin, Juxtapid, Kynamro: 6 Vascepa simvastatin or Crestor) within the last 130-days, the prescription will automatically process months Epanova at the pharmacy. All others: indefinite Prior Authorization will be required for prescriptions that do not process automatically at Repatha the pharmacy. Renewals require Praluent In those cases, Zetia will be authorized upon receipt of documentation to support the improvement in fasting diagnosis of hyperlipidemia and failure of, or contraindication to atorvastatin, simvastatin, lipids and documentation Juxtapid and Crestor. of recommended safety Kynamro monitoring parameters Non-formulary medications for hypertriglyceridemia (Lovaza, Vascepa, and Epanova) (such as liver enzymes) can be approved when the following criteria are met: Patient is at 18 years old Drug will be used as an add-on to lifestyle interventions to include diet and exercise Treatment of severe hypertriglyceridemia (triglyceride level greater than or equal to 500 mg/dL) Trial and failure of OTC fish oil and at least ONE other formulary medication such as fenofibrate, fenofibric acid, gemfibrozil, or niacin or contraindication to all formulary agents PCSK9 Inhibitors (Repatha and Praluent) can be approved when ALL of the following criteria are met: Lab results support an LDL mg/dL (within the past 90 days) ≥300
30 days for three months Renewal: 3 months Hyperlipidemia Medications Last reviewed: 6/15/15 Crestor Zetia Lovaza Vascepa Epanova Repatha Praluent Juxtapid Kynamro Crestor can be approved when the following criteria are met: Patient is at least 10 years old; AND Patient has failed to achieve LDL goal on a compliant regimen of maximum tolerated dose of atorvastatin; OR Patient requires a high intensity statin (i.e., diagnosis of familial hypercholesterolemia or high ASCVD risk per provider evaluation) AND patient had a trial and failure of atorvastatin requires step therapy: If member has filled 2 prescriptions for 2 different statins (specifically atorvastatin, simvastatin or Crestor) within the last 130-days, the prescription will automatically process at the pharmacy. Prior Authorization will be required for prescriptions that do not process automatically at the pharmacy. In those cases, Zetia will be authorized upon receipt of documentation to support the diagnosis of hyperlipidemia and failure of, or contraindication to atorvastatin, simvastatin, and Crestor. Non-formulary medications for hypertriglyceridemia (Lovaza, Vascepa, and Epanova) can be approved when the following criteria are met: Patient is at 18 years old Drug will be used as an add-on to lifestyle interventions to include diet and exercise Treatment of severe hypertriglyceridemia (triglyceride level greater than or equal to 500 mg/dL) Trial and failure of OTC fish oil and at least ONE other formulary medication such as fenofibrate, fenofibric acid, gemfibrozil, or niacin or contraindication to all formulary agents PCSK9 Inhibitors (Repatha and Praluent) can be approved when ALL of the following criteria are met: Lab results support an LDL ≥300 mg/dL (within the past 90 days) Initial Approval: PSCK9 inhibitors: 3 months Juxtapid, Kynamro: 3 months All others: 6 months Renewal: inhibitors: 6 months Juxtapid, Kynamro: 6 months All others: indefinite Renewals require improvement in fasting lipids and documentation of recommended safety monitoring parameters (such as liver enzymes)
MMIC-PA-SMI-Guidelines.docx