Vascepa — Blue Cross Blue Shield of Kansas

Initial criteria

• Patient has an FDA labeled indication OR indication supported in compendia for the requested agent and route of administration
• If patient has an FDA labeled indication, ONE of the following: (A) Age is within FDA labeling for the requested indication for the requested agent OR (B) Support for using the requested agent for the patient’s age for the requested indication
• ONE of the following: (A) Requested agent is a preferred agent OR (B) Requested agent is a non-preferred agent AND patient has ONE of the following: (1) Intolerance or hypersensitivity to the preferred agent not expected with the requested agent OR (2) FDA labeled contraindication to ALL preferred agents not expected with the requested agent
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s PA process
• Patient has had clinical benefit with the requested agent
• ONE of the following: (A) Requested agent is a preferred agent OR (B) Requested agent is a non-preferred agent AND patient has ONE of the following: (1) Intolerance or hypersensitivity to the preferred agent not expected with the requested agent OR (2) FDA labeled contraindication to ALL preferred agents not expected with the requested agent
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months