icosapent ethyl — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following: (A) patient has a 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:
•  1. ONE of the following: (A) patient is on maximally tolerated statin therapy OR (B) has intolerance or hypersensitivity to statin therapy OR (C) has FDA labeled contraindication to ALL statins
•  2. patient has fasting triglyceride level ≥ 135 mg/dL
•  3. ONE of the following: (A) patient has established cardiovascular disease OR (B) patient has diabetes mellitus AND two or more additional risk factors for cardiovascular disease
•  4. OR patient has another FDA labeled indication for requested agent and route OR indication supported in compendia
• If patient has FDA labeled indication, then ONE of the following: (A) patient’s age is within FDA labeling for requested indication OR (B) there is support for using agent for patient’s age for requested indication
• patient does NOT have any FDA labeled contraindications to requested agent
• Compendia allowed: AHFS or DrugDex level 1, 2A, or 2B
• For members residing in Ohio AND plan is Fully Insured or HIM Shop (SG): agent approved when no FDA labeled contraindications AND ONE of: (A) another FDA labeled indication OR (B) indication supported in compendia (DrugDex 1, 2A, 2B; AHFS-DI supportive) OR (C) prescriber submitted TWO peer-reviewed journal articles supporting proposed use (case studies not acceptable)

Reauthorization criteria

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

Approval duration

12 months