1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)?

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1 09/07/2016 Prior Authorization AETA BETTER HEALTH OF KETUCK (MEDICAID) PCSK9 Inhibitors (K88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health of Kentucky at Please contact Aetna Better Health of Kentucky at with questions regarding the Prior Authorization process. When conditions are met, we will authorize the coverage of PCSK9 Inhibitors (K88). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (select from list of drugs shown) Praluent (alirocumab) Repatha (evolocumab) Other, Please specify Quantity Frequency Strength Route of Administration Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Expected Length of therapy Prescribing Physician Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. Question Requests for PCSK9 Inhibitors will only be accepted by fax and with the appropriate medical records and lab results. Requests will not be taken over the phone. 1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? [If no, skip to question 5.] 2. Has treatment with this medication resulted in an improvement in fasting lipids? OTE: Results of fasting lipid profile must be submitted with renewal requests.

2 3. Does the patient have liver function tests (LFT s) within normal range while on the requested medication? OTE: Results of LFT s must be submitted with renewal requests. 4. Is the patient compliant with concomitant lipid lowering medications (e.g., statins, Zetia, niacin, or bile acid sequestrant)? OTE: Pharmacy claim history will be reviewed to confirm refills. [o further questions.] 5. Is the patient unable to tolerate statins? OTE: Medical records must be submitted supporting that skeletal muscle related symptoms occurred while taking 2 different statins (at least one being a moderate to high potency statin) and the symptoms resolved when statin therapy was discontinued and that the patient has been rechallenged at a lower dose or with a different statin. [If yes, skip to question 8.] 6. Has the patient had separate trials of at least 60 days each with atorvastatin and rosuvastatin at maximum tolerated doses used in combination with Zetia, niacin, or a bile acid sequestrant? OTE: Pharmacy claim history will be reviewed to confirm refills. Please document medication regimens tried and reason for treatment failure: 7. Will the requested drug be used in combination with a statin at a maximum tolerated dose? 8. Will the requested drug also be used in combination with Zetia, niacin, a bile acid sequestrant, or LDL apheresis? Please document which treatment(s) will be used:

3 9. Does the patient have a diagnosis of HETEROZGOUS familial hypercholesterolemia (HeFH)? [If no, skip to question 12.] 10. Is the diagnosis confirmed by at least OE of the following: A) DA based evidence of an LDL receptor (LDLR) mutation, APO-B100, or PCSK9 mutation; B) Who/Dutch Lipid etwork Criteria result with a score of greater than 8 points; C) History of an LDL-C greater than 190 mg/dl at any time AD physical evidence of tendon xanthomas OR evidence of these signs in a 1st or 2nd degree relative? OTE: Medical records to support diagnosis must be submitted with 11. Does the patient have a fasting lipid profile within the previous 90 days that confirmed an LDL-C greater than or equal to 70mg/dL on the current OTE: Results of fasting lipid profile must be submitted with request. [If yes, skip to question 21.] 12. Does the patient have a diagnosis of HOMOZGOUS familial hypercholesterolemia (HoFH)? [If no, skip to question 19.] 13. Does the patient have genetic confirmation of 2 mutant alleles at LDLR, APO-B100, or PCSK9? OTE: Medical records to support diagnosis must be submitted with [If yes, skip to question 16.] 14. Does the patient have a history of an LDL-C greater than or equal to 300mg/dL on maximum dosed statin OR an LDL-C greater than or equal to 500mg/dL at any time? OTE: Results of fasting lipid profile must be submitted with request.

4 15. Do BOTH of the patient s parents have HeFH OR did the patient have cutaneous xanthoma(s) present before the age of 10? OTE: Medical records to support diagnosis must be submitted with 16. Does the patient have a fasting lipid profile within the previous 90 days that confirmed an LDL-C reduction of less than 50 percent on the current OTE: Results of fasting lipid profile must be submitted with request. 17. Is the request for Repatha? 18. Is the patient at least 13 years old? [o further questions.] 19. Does the patient have clinical atherosclerotic cardiovascular disease (ASCVD)? OTE: Evidence to support clinical ASCVD (i.e., history of acute coronary syndrome, history of MI, stable or unstable angina, coronary or other revascularization (PCI/CABG), stroke, TIA, peripheral arterial disease presumed to be of atherosclerotic origin must be submitted with request. 20. Does the patient have a fasting lipid profile within the previous 90 days that confirmed an LDL-C greater than or equal to 70mg/dL on the current OTE: Results of fasting lipid profile must be submitted with request.

5 21. Is the patient at least 18 years old? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date