Lovaza — Medical Mutual
Severe hypertriglyceridemia (triglyceride ≥ 500 mg/dL)
Initial criteria
- Patient age ≥ 18 years; AND
- Fasting baseline triglyceride (TG) level > 500 mg/dL; AND
- Tried or currently receiving ONE of the following for ≥ 90 days with inadequate efficacy: fibrate (e.g. gemfibrozil, fenofibrate, fenofibric acid) OR statin (e.g. atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin) OR OTC omega-3 fatty acid product at maximum recommended dosage; AND
- Patient has been on and will continue appropriate lipid-lowering diet and exercise regimen; AND
- If brand Lovaza is requested, patient has failed trial of generic omega-3 acid ethyl esters for ≥ 90 days
Reauthorization criteria
- Response to therapy is required for continuation of therapy
Approval duration
1 year initial, 1 year reauth