Tryngolza (olezarsen subcutaneous injection) — Cigna

Familial Chylomicronemia Syndrome

Initial criteria

Patient is age ≥ 18 years; AND
Patient has a fasting triglyceride level ≥ 880 mg/dL [documentation required]; AND
Patient has undergone genetic testing and meets ONE of the following (i or ii):
i. Molecular genetic test results demonstrate biallelic pathogenic variants in at least one gene causing familial chylomicronemia syndrome [documentation required]; OR
ii. Molecular genetic test results are inconclusive and the patient has ONE of the following (a, b, c, d, or e) [documentation required]:
a) Patient has a familial chylomicronemia syndrome score ≥ 10; OR
b) Patient has a North American familial chylomicronemia syndrome score ≥ 45; OR
c) Patient has a history of pancreatitis; OR
d) Patient has a history of eruptive xanthomas; OR
e) Patient has a history of lipemia retinalis; AND
The medication will be used concomitantly with a low-fat diet; AND
Medication is prescribed by a cardiologist, an endocrinologist, or a physician who focuses in the treatment of disorders related to severe hypertriglyceridemia.

1 year