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The Policy VaultThe Policy Vault

Nexlizet — Blue Cross Blue Shield of Kansas

Reducing the risk of myocardial infarction and coronary revascularization in adults with high risk for a cardiovascular disease (CVD) event or established CVD (including acute coronary syndrome, history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, peripheral arterial disease including aortic aneurysm)

Initial criteria

  • ONE of the following:
  • A. BOTH of the following:
  • 1. The patient has a diagnosis of ONE of the following: Primary hyperlipidemia (including heterozygous familial hypercholesterolemia [HeFH]) OR reducing the risk of myocardial infarction and coronary revascularization with high risk for CVD event OR established CVD (acute coronary syndrome, history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, peripheral arterial disease including aortic aneurysm, presumed to be of atherosclerotic origin)
  • 2. ONE of the following:
  • A. The patient has tried and had an inadequate response to at least ONE statin OR
  • B. The patient is statin intolerant defined as experiencing ONE of the following: Statin-related rhabdomyolysis OR Statin-related skeletal muscle symptoms (e.g., myopathy, myalgia) OR Statin-related elevated hepatic transaminase OR
  • C. The patient has a hypersensitivity to at least ONE statin OR
  • D. The patient has an FDA labeled contraindication to ALL statins
  • OR
  • B. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • C. The patient has another indication supported in compendia (AHFS or DrugDex 1 or 2a level of evidence) for the requested agent and route of administration
  • AND
  • If the patient has an FDA labeled indication, then ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • B. There is support for using the requested agent for the patient’s age for the requested indication
  • AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
  • The patient has had clinical benefit with the requested agent
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months