Limited coverage criteria – icosapent ethyl

icosapent ethyl

1 gram capsule

As combination therapy with an HMG-CoA reductase inhibitor (statin) for the secondary prevention of established cardiovascular disease in patients 45 years of age and older who meet ALL of the following criteria:

Patient has a fasting triglyceride level of 1.7mmol/L or greater and lower than 5.6 mmol/L at baselines, measured within the preceding three months before starting treatment with icosapent ethyl

AND
 

Patient has a low-density lipoprotein cholesterol (LDL-C) level greater than 1 mmol/L and lower than 2.6 mmol/L at baseline

AND
 

Patient is receiving maximally tolerated statin therapy for a minimum of 4 weeks, targeted to achieve an LDL-C level lower than 1.8 mmol/L for secondary prevention

Indefinite