Praluent — Highmark

Primary Hyperlipidemia not associated with ASCVD, HeFH, or HoFH

Preferred products

Member age ≥ 18 years
Diagnosis of primary hyperlipidemia not associated with ASCVD, HeFH, or HoFH
Member has CAC score ≥ 1,000 Agatston units OR baseline untreated LDL ≥ 190 mg/dL
Member has experienced therapeutic failure to a maximally tolerated statin OR is statin intolerant as defined by (a) at least two separate statin trials with rhabdomyolysis or muscle symptoms resolving upon discontinuation OR (b) CK ≥ 10× ULN, LFTs ≥ 3× ULN, or hospitalization due to severe statin-related adverse event
Member meets one of: current LDL-C ≥ 70 mg/dL, current non-HDL-C ≥ 100 mg/dL, or < 50% reduction in baseline LDL-C despite maximally tolerated statin therapy
If request is for Praluent, member has experienced therapeutic failure or intolerance to plan-preferred Repatha

Member age ≥ 18 years
Diagnosis of primary hyperlipidemia not associated with ASCVD, HeFH, or HoFH persists
Prior to therapy member met one of: CAC score ≥ 1,000 Agatston units or baseline untreated LDL ≥ 190 mg/dL
Prior to therapy member met one of: current LDL-C ≥ 70 mg/dL, current non-HDL-C ≥ 100 mg/dL, or < 50% LDL-C reduction despite maximally tolerated statin
Member has achieved at least 30% reduction in LDL-C from baseline OR LDL-C < 70 mg/dL

initial 6 months (12 months for Delaware Commercial fully-insured/ACA); reauthorization 12 months