Repatha — Medica

Primary hyperlipidemia

Initial criteria

Approve if ALL of the following (i, ii, and iii) are met:
i. age ≥ 18 years; AND
ii. ONE of the following:
a) coronary artery calcium or calcification score ≥ 300 Agatston units; OR
b) diabetes; AND
iii. ONE of the following:
a) ALL of the following:
(1) tried one high-intensity statin (atorvastatin ≥ 40 mg daily or rosuvastatin ≥ 20 mg daily); AND
(2) tried that statin along with ezetimibe (single-entity or combination) for ≥ 8 continuous weeks; AND
(3) LDL‑C after this regimen remains ≥ 70 mg/dL; OR
b) statin‐intolerant, defined as EITHER:
(1) statin‐related rhabdomyolysis; OR
(2) ALL of the following:
(a) skeletal‐related muscle symptoms (e.g., myopathy or myalgia); AND
(b) symptoms occurred during separate trials of both atorvastatin and rosuvastatin (single‑entity or combination); AND
(c) symptoms resolved upon discontinuation of each statin

Approve if according to the prescriber, the patient has experienced a response to therapy (e.g., decreased LDL‑C, total cholesterol, non‑HDL‑C, or apolipoprotein B levels).
If currently receiving Repatha without prior approval for this indication, review under Initial Therapy criteria.
If restarting Repatha, Initial Therapy criteria must be met.

1 year