Vascepa — Blue Cross Blue Shield of Oklahoma

severe hypertriglyceridemia (fasting triglyceride level ≥ 500 mg/dL)

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

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

12 months