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Limited coverage criteria – ezetimibe

Last updated on August 13, 2026

 

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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 1 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

  • 1Target LDL-C levels are:
    • For primary prevention, a ≥ 50% reduction in LDL-C from untreated baseline
    • For secondary prevention, an LDL-C < 1.8 mmol/L or non-HDL-C < 2.4 mmol/L or ApoB < 0.7 g/L
  • Ezetimibe is a regular benefit for Plan W (First Nations Health Benefits) recipients

Special Authority request form(s)