Vascepa (icosapent ethyl capsules – Amarin, generic) — Cigna

Initial criteria

• Patient meets ONE of the following (i or ii): i. Patient has established cardiovascular disease; OR ii. Patient meets BOTH of the following (a and b): a) Patient has diabetes; AND b) According to the prescriber, patient has at least two additional risk factors for cardiovascular disease
• Prior to initiation of therapy, the patient had a fasting baseline triglyceride level ≥ 150 mg/dL
• Patient meets ONE of the following (i or ii): i. Patient is receiving statin therapy; OR ii. According to the prescriber, patient cannot tolerate statin therapy

Approval duration

1 year