Rezdiffra — Highmark

Initial criteria

• The prescriber provides documentation that the member continues to use standard of care pharmacologic treatment to manage comorbid diseases (for example, cardiovascular disease, dyslipidemia, diabetes, hypertension).
• The prescriber provides documentation that the member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC).
• The prescriber provides documentation that the member’s alcohol consumption is ≤ 20 g/day in females or ≤ 30 g/day for males.

Reauthorization criteria

• The prescriber provides documentation that the member continues to meet initial criteria.

Approval duration

initial: 12 months; reauthorization: 12 months