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Limited coverage criteria – ezetimibe

Publication date: December 18, 2018

 

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Generic name

ezetimibe                   

Strength & form

10 mg 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

  • 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
  • Ezetimibe is a regular benefit for Plan W (First Nations Health Benefits) recipients

Special Authority request form(s)