ATORVALIQ (atorvastatin)

ATORVALIQ (atorvastatin)

Self-Administration – oral

Diagnosis considered for coverage:

• FDA-approved for the condition being treated

Coverage Criteria:

For diagnosis of FDA-approved for the condition being treated:

• Dose does not exceed 80mg, AND
• If the request for an off-label guideline approval criterion have been met AND
• One of the following
  • Trial and failure, or intolerance to a generic equivalent of the requested drug in a sold dosage form OR
  • Patient is unable to swallow a solid dosage form (e.g., oral tablet, capsule) due to one of the following: Age, Physical impairment (difficulties with motor or oral coordination), Dysphagia, Patient using a feeding tube or nasal gastric tube

Coverage Duration: 

• Initial: 12 months
• Reauthorization: none

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.
 

Policy Updates:

• 3/1/2024 (policy effective date) – New policy approved by WHA P&T Committee. (P&T, 2/20/2024) (P&T meeting date)  

References:

• Atorvastatin. IBM Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Accessed December 5, 2023. http://www.micromedexsolutions.com.