Repatha — Medical Mutual

Initial criteria

• Patient age ≥ 18 years AND
• Patient has one of the following: coronary artery calcium score ≥ 300 Agatston units OR diabetes AND
• Patient meets one of the following: (a) Patient has tried one high-intensity statin (atorvastatin ≥ 40 mg daily OR rosuvastatin ≥ 20 mg daily) AND ezetimibe combination for ≥ 8 continuous weeks AND LDL-C remains ≥ 70 mg/dL OR (b) Patient is statin intolerant by rhabdomyolysis OR experienced skeletal-related muscle symptoms during trials of both atorvastatin and rosuvastatin that resolved on 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