Limited Coverage Drugs - ezetimibe

Generic Name

ezetimibe                   

Strength

10 mg

Form

tablet

Special Authority Criteria

Approval Period

For the treatment of hypercholesterolemia in patients with established cardiovascular disease who are at high risk for future events:

  • as an adjunct to maximally tolerated statin therapy in adult patients, when the patient is unable to reach target LDL-C levels i with maximally tolerated HMG-CoA Reductase Inhibitors (statins).

    OR
     
  • if the patient is unable to tolerate at least 2 HMG-CoA Reductase Inhibitors (statins).

Indefinite

Practitioner Exemptions

  • None

Special Notes

  1. Target LDL-C levels are:
    • For primary prevention, a ≥50% reduction in LDL-C from untreated baseline.
    • For secondary  prevention, an LDL-C ˂ 2.0 mmol/L.
  2. Ezetimibe is a regular benefit for Plan W (First Nations Health Benefits) recipients.

Special Authority Request Form(s)