Juxtapid (lomitapide capsules - Amryt) — Cigna
Homozygous Familial Hypercholesterolemia (HoFH)
Preferred products
- Repatha (evolocumab subcutaneous injection)
- Praluent (alirocumab subcutaneous injection)
Initial criteria
- Patient is age ≥ 18 years; AND
- Patient meets ONE of the following (a, b, or c):
- a) Patient has phenotypic confirmation of homozygous familial hypercholesterolemia; OR
- b) Patient has an untreated low-density lipoprotein cholesterol (LDL-C) level > 400 mg/dL AND meets ONE of the following [(1) or (2)]:
- (1) Patient had clinical manifestations of homozygous familial hypercholesterolemia before 10 years of age; OR
- (2) At least one parent of the patient had untreated LDL-C or total cholesterol levels consistent with familial hypercholesterolemia; OR
- c) Patient has a treated LDL-C level ≥ 300 mg/dL AND meets ONE of the following [(1) or (2)]:
- (1) Patient had clinical manifestations of homozygous familial hypercholesterolemia before 10 years of age; OR
- (2) At least one parent of the patient had untreated LDL-C or total cholesterol levels consistent with familial hypercholesterolemia; AND
- Patient meets ONE of the following (a or b):
- a) Patient meets BOTH of the following [(1) and (2)]:
- (1) Patient has tried at least one proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitor for ≥ 8 continuous weeks; AND
- (2) LDL-C level after this PCSK9 inhibitor therapy remains ≥ 70 mg/dL; OR
Reauthorization criteria
- Patient is currently receiving Juxtapid therapy.
Approval duration
1 year