Repatha — Medical Mutual

Initial criteria

• Patient age ≥ 10 years AND
• Patient meets one of the following: untreated LDL-C ≥ 190 mg/dL prior to therapy OR diagnosis confirmed by genetic testing OR diagnosis confirmed by Dutch Lipid Network score > 5 OR Simon Broome criteria definite/possible familial hypercholesterolemia AND
• Patient meets one of the following: (a) Tried high-intensity statin therapy (atorvastatin ≥ 40 mg daily OR rosuvastatin ≥ 20 mg daily) for ≥ 8 continuous weeks AND LDL-C remains ≥ 70 mg/dL OR (b) Statin intolerant by rhabdomyolysis OR experienced muscle symptoms with both atorvastatin and rosuvastatin that resolved upon discontinuation

Reauthorization criteria

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

Approval duration

1 year