Icosapent Ethyl (generic Vascepa) (Revised)

Before July 10, 2024: Billing and prior authorization teams must implement the revised icosapent ethyl (generic Vascepa) authorization criteria in the billing system and claims processing workflows. (1) Update PA submission requirements to verify the member meets BOTH of the following: (a) Triglyceride level documentation (≥150 mg/dL for risk reduction pathway; ≥500 mg/dL for severe hypertriglyceridemia pathway), (b) Evidence of established cardiovascular disease OR Type 2 Diabetes with CV risk factors (for risk reduction only), and (c) Documentation of prior treatment, intolerance, or contraindication to brand Vascepa. (2) For risk reduction pathway: Confirm concurrent medication record includes a generic statin (atorvastatin, rosuvastatin, lovastatin, pravastatin), fenofibrate, OR ezetimibe. (3) For severe triglyceridemia: Confirm fenofibrate is on concurrent medication list. (4) Notify providers through EMR alerts, claim scrubbing rules, and prior auth submission portals of the dual-pathway requirement and medication prerequisite changes. (5) Set approval duration to initial plan year only—do not auto-extend. Failure to enforce these criteria will result in claim denials. Flag all requests that lack triglyceride level documentation, CV disease/risk factor evidence, or required concomitant medications for manual medical director review. Refer providers to Humana's TAD portal (http://apps.humana.com/tad/tad_new/home.aspx) for current policy version verification.