Nexlizet — Blue Cross Blue Shield of Texas

Initial criteria

• 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 AND has ONE of: Acute coronary syndrome, History of myocardial infarction, Stable or unstable angina, Coronary or other arterial revascularization, Stroke, Transient ischemic attack, or Peripheral arterial disease (including aortic aneurysm presumed to be of atherosclerotic origin)
• 2. ONE of the following regarding statins: inadequate response to ≥1 statin OR intolerance due to rhabdomyolysis, skeletal muscle symptoms, elevated hepatic transaminase, hypersensitivity to ≥1 statin, or FDA labeled contraindication to all statins
• B. The patient has another FDA labeled indication for the requested agent and route of administration OR the patient has another indication that is supported in compendia for the requested agent and route of administration
• 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
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

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

Approval duration

12 months (36 months for BCBSOK)