REPATHA (evolocumab) — CareFirst (Caremark)

Initial criteria

• Member meets either of the following for baseline LDL-C: (i) age ≥ 18 years and untreated LDL-C ≥ 190 mg/dL in absence of secondary cause, or (ii) age < 18 years and untreated LDL-C ≥ 160 mg/dL in absence of secondary cause.
• Member meets either of the following for treatment response: (i) age ≥ 10 years and has current LDL-C ≥ 100 mg/dL after at least three months of treatment with a high-intensity statin dose in combination with ezetimibe (or moderate-intensity if unable to tolerate) OR has current LDL-C ≥ 100 mg/dL with contraindication or intolerance to statins (Appendix B criteria), OR (ii) age 8 to <10 years and request is for Praluent, and has current LDL-C ≥ 100 mg/dL after at least three months of treatment with a high-intensity statin dose (or moderate-intensity if unable to tolerate) OR has current LDL-C ≥ 100 mg/dL with contraindication or intolerance to statins (Appendix B criteria).

Reauthorization criteria

• Member has achieved or maintained an LDL-C reduction (LDL-C now at goal or shows robust lowering).

Approval duration

12 months