Other Dyslipidemia Drugs
PDL Reference Documents
- Bempedoic Acid Indication Update - Dec 07, 2023
- PCSK9 Modulators - Aug 04, 2022
- Non-Statin Dyslipidemia Drugs - Aug 05, 2021
- Non-statin Dyslipidemia Drugs - Aug 06, 2020
- Non-statin Lipid Lowering Agents - May 23, 2019
- PCSK9 Inhibitors - Jan 25, 2018
- Non-statin Lipid-lowering Agents - Nov 17, 2016
- PCSK9 Inhibitors - Nov 19, 2015
- Other Lipotropics - Sep 23, 2014
- Omega-3 Fatty Acids Prior Authorization Criteria - Mar 27, 2014
- Fish Oil Class Review - Jan 30, 2014
- Class Update: Other Lipid Lowering Agents - Sep 26, 2013
- Abbreviated Class Review: Non-Statin Lipid Lowering Agents - May 31, 2012
Drug Use Review Documents
Newsletters
- August 2022 - An Update in Lipid Lowering Therapies
- March 2019 - Non-statin Low-Density Lipoprotein Cholesterol (LDL-C) Lowering Therapy and Cardiovascular Outcomes
- May 2014 - New Cholesterol Guidelines: A Significant Shift in Cholesterol Management
- March 2014 - Evidence Based Review of Fish Oil: Going Beyond the Headlines
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.
Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
---|---|---|---|---|---|
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 | ||
cholestyramine/aspartame | CHOLESTYRAMINE LIGHT | POWD PACK | Y | ||
cholestyramine/aspartame | PREVALITE | POWD PACK | Y | ||
cholestyramine/aspartame | CHOLESTYRAMINE LIGHT | POWDER | Y | ||
cholestyramine/aspartame | PREVALITE | POWDER | Y | ||
cholestyramine/aspartame | QUESTRAN LIGHT | POWDER | Y | ||
evolocumab | REPATHA SURECLICK | PEN INJCTR | Y | PA Document | |
evolocumab | REPATHA SYRINGE | SYRINGE | Y | PA Document | |
evolocumab | REPATHA PUSHTRONEX | WEAR INJCT | Y | PA Document | |
ezetimibe | ZETIA | TABLET | Y | ||
ezetimibe | EZETIMIBE | TABLET | Y | ||
fenofibrate | FENOFIBRATE | TABLET | Y | ||
fenofibrate nanocrystallized | TRICOR | TABLET | Y | ||
fenofibrate nanocrystallized | FENOFIBRATE | TABLET | Y | ||
fenofibrate,micronized | FENOFIBRATE | CAPSULE | Y | ||
fenofibric acid (choline) | TRILIPIX | CAPSULE DR | Y | ||
fenofibric acid (choline) | FENOFIBRIC ACID | CAPSULE DR | Y | ||
omega-3 acid ethyl esters | OMEGA-3 ACID ETHYL ESTERS | CAPSULE | Y | PA Document | |
omega-3 acid ethyl esters | LOVAZA | CAPSULE | Y | PA Document | |
alirocumab | PRALUENT PEN | PEN INJCTR | N | PA Document | |
bempedoic acid | NEXLETOL | TABLET | N | PA Document | |
bempedoic acid/ezetimibe | NEXLIZET | TABLET | N | PA Document | |
choline | CHOLINE | TABLET | N | ||
colesevelam HCl | WELCHOL | POWD PACK | N | ||
colesevelam HCl | COLESEVELAM HCL | POWD PACK | N | ||
colesevelam HCl | WELCHOL | TABLET | N | ||
colesevelam HCl | COLESEVELAM HCL | TABLET | N | ||
colestipol HCl | COLESTIPOL HCL | GRANULES | N | ||
colestipol HCl | COLESTID | GRANULES | N | ||
colestipol HCl | COLESTIPOL HCL | PACKET | N | ||
colestipol HCl | COLESTID | PACKET | N | ||
colestipol HCl | COLESTIPOL HCL | TABLET | N | ||
colestipol HCl | COLESTID | TABLET | N | ||
evinacumab-dgnb | EVKEEZA | VIAL | N | PA Document | |
fenofibrate | LIPOFEN | CAPSULE | N | ||
fenofibrate | FENOFIBRATE | CAPSULE | N | ||
fenofibrate | FENOGLIDE | TABLET | N | ||
fenofibrate | FENOFIBRATE | TABLET | N | ||
fenofibric acid | FIBRICOR | TABLET | N | ||
gemfibrozil | GEMFIBROZIL | TABLET | N | ||
gemfibrozil | LOPID | TABLET | N | ||
icosapent ethyl | ICOSAPENT ETHYL | CAPSULE | N | PA Document | |
inclisiran sodium | LEQVIO | SYRINGE | N | PA Document | |
inositol | INOSITOL | TABLET | N | ||
lomitapide mesylate | JUXTAPID | CAPSULE | N | Jul 25, 2013 | |
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 | ||
niacinamide | VITAMIN B3 | TABLET |