Nexlizet — Blue Cross Blue Shield of Oklahoma

Initial criteria

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

Reauthorization criteria

• ALL of the following:
• 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• 2. The patient has had clinical benefit with the requested agent
• 3. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

BCBSOK: 36 months; others: 12 months