ModifiedMolina HealthcarePolicy C30342-A

Redemplo (plozasiran) Coverage Criteria

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Coverage and prior authorization requirements for Redemplo (plozasiran) used with diet to reduce triglycerides in adults with familial chylomicronemia syndrome.

Policy Summary

PayerMolina Healthcare

PolicyRedemplo (plozasiran) Coverage Criteria

Policy CodePolicy C30342-A

Change TypeNew coverage criteria

Effective DateMar 13, 2026

Next Review DateJan 1, 2027

Key ActionSubmit documentation of FCS diagnosis and at least one qualifying confirmation feature with the prior authorization request.

SourceLink

POLICY UPDATE CHANGES

New coverage criteria were created for Redemplo (plozasiran) in Q1 2026.

18+Minimum member age

≥10 mmol/LRequired fasting triglycerides

12 monthsInitial authorization

25 mg/3 monthsDose schedule

≤20 g/dayLow-fat diet

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