Repatha — Highmark

Preferred products

• Repatha

Initial criteria

• Member age ≥ 18 years
• Diagnosis of ASCVD substantiated by at least one of: acute coronary syndrome, coronary or other arterial revascularization, history of myocardial infarction, history of stroke, history of transient ischemic attack, peripheral arterial disease presumed atherosclerotic, or stable/unstable angina
• 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: LDL-C ≥ 70 mg/dL, non-HDL-C ≥ 100 mg/dL, meets very high-risk criteria with LDL-C ≥ 55 mg/dL or non‑HDL‑C ≥ 85 mg/dL, or < 50% reduction in baseline LDL-C despite maximally tolerated statin
• If the request is for Praluent, member has experienced therapeutic failure or intolerance to plan-preferred Repatha

Reauthorization criteria

• Member age ≥ 18 years
• Diagnosis of ASCVD substantiated as for initiation
• Prior to therapy member met one of: LDL-C ≥ 70 mg/dL, non-HDL-C ≥ 100 mg/dL, or very high-risk criteria with LDL-C ≥ 55 mg/dL or non‑HDL‑C ≥ 85 mg/dL, or < 50% LDL-C reduction despite maximally tolerated statin
• Member has achieved at least 30% reduction in LDL-C from baseline OR documented LDL-C < 70 mg/dL

Approval duration

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