Vascepa — Blue Cross Blue Shield of Kansas
severe hypertriglyceridemia (fasting triglyceride level ≥ 500 mg/dL)
Preferred products
- generic icosapent ethyl
Initial criteria
- ONE of the following: (A) Patient has diagnosis of severe hypertriglyceridemia (fasting triglyceride level ≥ 500 mg/dL) OR (B) Patient is using requested agent to reduce risk of myocardial infarction, stroke, coronary revascularization, or unstable angina requiring hospitalization AND ALL of the following:
- ONE of the following: (A) Patient is taking a maximally tolerated statin OR (B) Patient is statin intolerant defined as experiencing ONE of: statin-related rhabdomyolysis, statin-related skeletal muscle symptoms (e.g., myopathy, myalgia), or statin-related elevated hepatic transaminase OR (C) Patient has hypersensitivity to at least one statin OR (D) Patient has an FDA labeled contraindication to all statins
- Patient has fasting triglyceride level ≥ 135 mg/dL
- Patient has ONE of the following: (A) Diabetes mellitus AND TWO or more additional risk factors for cardiovascular disease OR (B) Established cardiovascular disease (CVD) AND ONE of: acute coronary syndrome, history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease including aortic aneurysm presumed to be of atherosclerotic origin