Other Dyslipidemia Drugs

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
cholestyramine CHOLESTYRAMINE LIGHT POWD PACK Y    
cholestyramine PREVALITE POWD PACK Y    
cholestyramine CHOLESTYRAMINE LIGHT POWDER Y    
cholestyramine QUESTRAN LIGHT POWDER Y    
cholestyramine PREVALITE POWDER Y    
cholestyramine (with sugar) CHOLESTYRAMINE POWD PACK Y    
cholestyramine (with sugar) QUESTRAN POWD PACK Y    
cholestyramine (with sugar) CHOLESTYRAMINE POWDER Y    
cholestyramine (with sugar) QUESTRAN POWDER Y    
evolocumab REPATHA SURECLICK PEN INJCTR Y Pharmacy PA  
evolocumab REPATHA SYRINGE SYRINGE Y Pharmacy PA  
evolocumab REPATHA PUSHTRONEX WEAR INJCT Y Pharmacy PA  
ezetimibe ZETIA TABLET Y    
ezetimibe EZETIMIBE TABLET Y    
fenofibrate FENOFIBRATE TABLET Y    
fenofibrate nanocrystallized FENOFIBRATE TABLET Y    
fenofibrate,micronized FENOFIBRATE CAPSULE Y    
fenofibric acid (choline) FENOFIBRIC ACID CAPSULE DR Y    
omega-3 acid ethyl esters OMEGA-3 ACID ETHYL ESTERS CAPSULE Y Pharmacy PA  
alirocumab PRALUENT PEN PEN INJCTR N Pharmacy PA  
bempedoic acid NEXLETOL TABLET N Pharmacy PA  
bempedoic acid/ezetimibe NEXLIZET TABLET N Pharmacy PA  
choline CHOLINE TABLET N    
colesevelam HCl WELCHOL POWD PACK N    
colesevelam HCl COLESEVELAM HCL POWD PACK N    
colesevelam HCl COLESEVELAM HCL TABLET N    
colesevelam HCl WELCHOL TABLET N    
colestipol HCl COLESTID GRANULES N    
colestipol HCl COLESTIPOL HCL GRANULES N    
colestipol HCl COLESTIPOL HCL PACKET N    
colestipol HCl COLESTID TABLET N    
colestipol HCl COLESTIPOL HCL TABLET N    
evinacumab-dgnb EVKEEZA VIAL N Pharmacy PA  
fenofibrate LIPOFEN CAPSULE N    
fenofibrate FENOFIBRATE CAPSULE N    
fenofibrate FENOFIBRATE TABLET N    
gemfibrozil GEMFIBROZIL TABLET N    
gemfibrozil LOPID TABLET N    
icosapent ethyl ICOSAPENT ETHYL CAPSULE N Pharmacy PA  
inclisiran sodium LEQVIO SYRINGE N Pharmacy PA  
inositol INOSITOL TABLET N Pharmacy PA  
lomitapide mesylate JUXTAPID CAPSULE N   Jul 25, 2013
May 26, 2016
niacin NIACIN CAPSULE ER N    
niacin NIACIN ER TAB ER 24H N    
niacin NIACIN TABLET N    
niacin NIACIN TABLET ER N    
niacin NIADELAY TABLET ER N    
niacin SLO-NIACIN TABLET ER N    
niacinamide NIACINAMIDE TABLET N    
niacinamide VITAMIN B3 TABLET N    
olezarsen sodium TRYNGOLZA AUTO INJCT N Pharmacy PA Feb 05, 2026
colestipol HCl COLESTIPOL HCL TABLET    
enlicitide decanoate LIPFENDRA TABLET Pharmacy PA  
niacinamide VITAMIN B3 TABLET    
olezarsen sodium TRYNGOLZA AUTO INJCT Pharmacy PA Feb 05, 2026
omega 3/dha/epa/other om3/D3 OMEGA-3 PLUS VITAMIN D3 LIQUID    
phytosterol/om-3/dha/epa/fish CARDIOSTEROL CAPSULE    
plozasiran sodium REDEMPLO SYRINGE Pharmacy PA