Self administration- Oral
Indications for Prior Authorization
- Treatment of adult patients homozygous familial hypercholesterolemia (HoFH)
Patients must meet the following criteria for the indication(s) above.
- Patient is on low fat diet and other lipid lowering medications with inadequate response
- All patients must undergo genetic testing to confirm HoFH status
The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee.
- All non-FDA approved uses not listed in the approved indications
- Initial dose 5 mg orally once a day
- Increase to 10 mg daily after at least two weeks based on tolerability
- At four week intervals increase to 20 mg, 40mg, 60 mg (maximum dose) daily if necessary based on efficacy and tolerability
- Box warnings for: hepatotoxicity
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: March 2013 Reviewed: December 2013