Nexletol — Cigna

Primary Hyperlipidemia

Initial criteria

Patient meets ALL of the following (i, ii, and iii):
i. Patient is ≥ 18 years of age; AND
ii. Patient meets ONE of the following (a or b): (a) Coronary artery calcium or calcification score ≥ 300 Agatston units; OR (b) Patient has diabetes; AND
iii. Patient meets ONE of the following (a or b):
a) Patient meets ALL of the following [(1), (2), and (3)]: (1) Tried one high-intensity statin therapy (atorvastatin ≥ 40 mg daily; rosuvastatin ≥ 20 mg daily as single-entity or combination product); AND (2) Tried the high-intensity statin above plus ezetimibe (as single-entity or combination product) for ≥ 8 continuous weeks; AND (3) LDL-C after regimen remains ≥ 70 mg/dL; OR
b) Patient determined to be statin intolerant by ONE of the following [(1) or (2)]: (1) Statin-related rhabdomyolysis; OR (2) Patient meets ALL of the following [(a), (b), and (c)]: (a) Skeletal-related muscle symptoms; AND (b) Occurred while receiving separate trials of both atorvastatin and rosuvastatin (single-entity or combination products); AND (c) Symptoms resolved upon discontinuation of each respective statin therapy.

According to the prescriber, the patient has experienced a response to therapy (e.g., decreasing LDL-C, total cholesterol, non-HDL-C, or apolipoprotein B levels).

1 year