REPATHA (evolocumab) — CareFirst (Caremark)

Initial criteria

• Member age ≥ 18 years had an untreated (before any lipid-lowering therapy) LDL-C level ≥ 190 mg/dL in the absence of a secondary cause; OR member < 18 years had untreated LDL-C level ≥ 160 mg/dL in the absence of a secondary cause.
• Member age ≥ 10 years has a current LDL-C level ≥ 100 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 age ≥ 10 years has a current LDL-C level ≥ 100 mg/dL with a contraindication or intolerance to statins (see Appendix B).
• For members age 8 years to <10 years, for Praluent only: current LDL-C level ≥ 100 mg/dL after at least three months of treatment with a high-intensity statin dose (or moderate if intolerant), OR LDL-C ≥ 100 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