generic statins — Blue Cross Blue Shield of Kansas

Initial criteria

• The requested agent is a generic statin (MSC=Y) unless a generic statin is not available for the requested agent
• The requested statin is covered under the pharmacy benefit or has been approved through the coverage exception process
• There is support that the requested statin is medically necessary
• The requested statin is for use in the primary prevention of cardiovascular disease (CVD)
• The patient age ≥ 40 years and ≤ 75 years
• The patient has at least one of the following risk factors: dyslipidemia, diabetes, hypertension, or smoking
• The patient has a calculated 10-year risk of a cardiovascular event of ≥ 10% per the American College of Cardiology and American Heart Association’s ASCVD calculator

Approval duration

12 months