icosapent ethyl — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ONE of the following: (A) diagnosis of severe hypertriglyceridemia (fasting triglyceride level ≥ 500 mg/dL) OR (B) requested agent used to reduce risk of myocardial infarction, stroke, coronary revascularization, or unstable angina requiring hospitalization AND ALL of the following:
•  ONE of the following: (A) on maximally tolerated statin therapy OR (B) intolerance or hypersensitivity to statin therapy OR (C) FDA labeled contraindication to ALL statins
•  fasting triglyceride level ≥ 135 mg/dL
•  ONE of the following: (A) established cardiovascular disease OR (B) diabetes mellitus AND 2 or more additional risk factors for cardiovascular disease OR (C) another FDA labeled indication OR (D) another indication supported in compendia
• AND if the patient has an FDA labeled indication, ONE of the following: (A) age is within FDA labeling for the requested indication OR (B) there is support for using the agent for the patient’s age for the requested indication
• patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia allowed: AHFS or DrugDex level 1, 2A, or 2B
• Additional Ohio exception pathway: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND both (A) no FDA labeled contraindications AND (B) ONE of the following: (1) other FDA labeled indication OR (2) other indication supported in compendia OR (3) prescriber submitted two peer-reviewed journal articles supporting proposed use

Reauthorization criteria

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

Approval duration

12 months