Praluent — Medical Mutual

Primary hyperlipidemia not associated with CVD, HeFH, or HoFH

Initial criteria

Patient age ≥ 18 years; AND
Patient has one of the following: (a) Coronary artery calcium score ≥ 300 Agatston units; OR (b) Diabetes; AND
Patient meets one of: (a) Tried high-intensity statin (atorvastatin ≥ 40 mg daily OR rosuvastatin ≥ 20 mg daily) AND ezetimibe (single or combo) for ≥ 8 weeks AND LDL-C remains ≥ 70 mg/dL; OR (b) Statin intolerance (rhabdomyolysis OR muscle symptoms on separate trials of atorvastatin and rosuvastatin resolving upon discontinuation)

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

1 year