Praluent — Medical Mutual

Established cardiovascular disease

Initial criteria

Patient age ≥ 18 years; AND
Patient has had one of the following: previous myocardial infarction or history of acute coronary syndrome OR angina (stable or unstable) OR past history of stroke or transient ischemic attack OR coronary artery disease OR peripheral arterial disease OR coronary or other arterial revascularization procedure in the past; AND
Patient meets one of the following: (a) Tried one high-intensity statin (atorvastatin ≥ 40 mg daily OR rosuvastatin ≥ 20 mg daily) for ≥ 8 continuous weeks AND LDL-C remains ≥ 55 mg/dL; OR (b) Statin intolerance defined as: rhabdomyolysis OR muscle symptoms on separate trials of atorvastatin and rosuvastatin, with resolution upon discontinuation of each

Prescriber attests patient has experienced a response to therapy (e.g., decreased LDL-C, total cholesterol, non-HDL-C, or apolipoprotein B)

1 year