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Praluent (alirocumab) — Cigna

Homozygous Familial Hypercholesterolemia

Initial criteria

  • Prescriber confirms diagnosis of homozygous familial hypercholesterolemia
  • Patient has phenotypic confirmation of homozygous familial hypercholesterolemia (examples may include LDL receptor, apolipoprotein B, PCSK9, or LDL receptor adaptor protein 1 gene involvement)
  • Untreated LDL-C level > 400 mg/dL OR treated LDL-C level ≥ 300 mg/dL

Reauthorization criteria

  • 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)