REPATHA (evolocumab) — CareFirst (Caremark)

Initial criteria

• Member has a history of clinical ASCVD (see Appendix A).
• Member has a current LDL-C level ≥ 70 mg/dL after at least three months of treatment with a high-intensity statin dose in combination with ezetimibe; if unable to tolerate high-intensity statin, moderate-intensity statin may be used.
• OR Member has a current LDL-C level ≥ 70 mg/dL with a contraindication or intolerance to statins (see Appendix B).

Reauthorization criteria

• Member has achieved or maintained an LDL-C reduction (e.g., LDL-C is now at goal or robust lowering of LDL-C).

Approval duration

12 months