Tryngolza (olezarsen) — Blue Cross Blue Shield of Oklahoma

other FDA labeled indications

Initial criteria

ONE of the following: (A) Diagnosis of familial chylomicronemia syndrome (FCS) confirmed by (1) genetic confirmation of bi-allelic pathogenic variants in affected genes (e.g., LPL, ApoA5, ApoC2, LMF1, GPIHBP1, G3PDH1) OR (2) ALL of the following: (A) Fasting triglyceride (TG) levels >880 mg/dL for 3 consecutive measurements AND (B) Secondary causes of hypertriglyceridemia ruled out AND (C) History of pancreatitis or unexplained recurrent abdominal pain AND (D) No response (TG decrease <20%) to conventional lipid lowering therapies (fibrates, omega-3 fatty acids, statins, niacin, ezetimibe, PCSK9 inhibitors) OR (B) Another FDA labeled indication for the agent and route OR (C) Another compendia-supported indication for the agent and route
If patient has an FDA labeled indication: ONE of the following: (A) Patient’s age is within FDA labeling OR (B) There is support for use at the patient’s age
Prescriber is a specialist (cardiologist, endocrinologist, geneticist, lipidologist) or has consulted with a specialist
Patient has no FDA labeled contraindications to the requested agent

Patient was previously approved for the requested agent through the plan’s Prior Authorization process
Patient has had clinical benefit with the requested agent
Prescriber is a specialist (cardiologist, endocrinologist, geneticist, lipidologist) or has consulted with a specialist
Patient has no FDA labeled contraindications to the requested agent

12 months