Limited Coverage Drugs - ezetimibe

Generic Name



10 mg



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).

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


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)