Repatha (evolocumab) — Point32Health

management of primary or familial hyperlipidemia

Preferred products

For ASCVD: patient has a history of clinical ASCVD or has experienced a cardiovascular event
AND one of the following: (a) current LDL-C ≥ 70 mg/dL while on maximally tolerated statin therapy (if not contraindicated or intolerant), OR (b) current LDL-C ≥ 55 mg/dL while on maximally tolerated statin therapy (if not contraindicated or intolerant) and member is at very high risk of ASCVD events with one or more of: myocardial infarction in past 2 years, history of ≥2 myocardial infarctions, history of coronary artery bypass graft surgery, symptomatic peripheral artery disease, or diabetes mellitus
AND one of the following: (a) contraindication to statin therapy (e.g., rhabdomyolysis or allergic reaction), OR (b) statin intolerant to at least two statins, OR (c) currently on maximally tolerated statin dose
AND for Praluent requests only for patients age ≥ 10 years: patient has tried and failed or has intolerance to evolocumab (Repatha)
For primary or familial hyperlipidemia: documented diagnosis of primary or familial hyperlipidemia
AND current LDL-C ≥ 100 mg/dL while on maximally tolerated statin therapy (if not contraindicated or intolerant)
AND one of the following: (a) contraindication to statin therapy, OR (b) statin intolerance to at least two statins, OR (c) on maximally tolerated statin
AND for Praluent requests only for patients age ≥ 10 years: patient has tried and failed or has intolerance to evolocumab (Repatha)

Patient is adherent to the requested PCSK9 inhibitor (e.g., Repatha, Praluent) as defined by consistently filled over past 4 months
AND positive response to therapy confirmed by a reduction in LDL-C from baseline

12 months initial, 12 months renewal