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![]() Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: PCSK9 Inhibitors
Policy:
Under some plans, including plans that use an open or closed formulary, Praluent is subject to precertification. If precertification requirements apply, Aetna considers this medication to be medically necessary for those members who meet the following precertification criteria: For Praluent A documented diagnosis of one of the following: AND AND AND AND AND AND
Special Notes: **Diagnosis of Heterozygous familial hypercholesterolemia requires one of the following:
^The dose of statin used should be: -rosuvastatin 20mg or higher, or -atorvastatin 40mg or higher, or -simvastatin 40mg or higher
Unless one of the following conditions exist: -Adverse effects occurred at higher doses -Age over 65 -Body Mass Index < 18.5 -Impaired glucose tolerance or elevated fasting glucose exists -Concomitant use of medications such as cyclosporine, protease inhibitors, ritonavir, clarithromycin, itraconazole, ketoconazole, erythromycin, nefazodone, ritonavir, simeprevir, verapamil, diltiazem, dronedarone, amiodarone, amlodipine, or ranolazine
Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit. All criteria above must be met in order to obtain coverage of Praluent. Place of Service: Outpatient The above policy is based on the following references:
July 31, 2015 |
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Additional Information
*P = Preferred
FE = Formulary Excluded NP = Nonpreferred PR = Precertification QL = Quantity Limits AL = Age Limits ST = Step-Therapy ‡M EX = Medical Exception +RxStep=Rx Step ^ETM=Essential Therapy Management *The lists above are subject to change. Not all programs - for example step-therapy, precertification, and quantity limits - are available in all service areas. ![]() |
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