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 but eligible patients will encounter a co-pay at the pharmacy.
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 QUESTRAN LIGHT POWDER Y    
cholestyramine/aspartame CHOLESTYRAMINE LIGHT POWDER Y    
cholestyramine/aspartame PREVALITE POWDER Y    
fenofibrate FENOFIBRATE TABLET Y 120 mg, 40 mg Require PA  
gemfibrozil GEMFIBROZIL TABLET Y    
gemfibrozil LOPID TABLET Y    
niacin NIACIN TABLET Y    
alirocumab PRALUENT PEN PEN INJCTR N PA Document  
colesevelam HCl WELCHOL POWD PACK N    
colesevelam HCl WELCHOL TABLET N    
colestipol HCl COLESTID GRANULES N    
colestipol HCl COLESTIPOL HCL GRANULES N    
colestipol HCl COLESTID PACKET N    
colestipol HCl COLESTIPOL HCL PACKET N    
colestipol HCl COLESTIPOL HCL TABLET N    
colestipol HCl COLESTID TABLET N    
evolocumab REPATHA SURECLICK PEN INJCTR N PA Document  
evolocumab REPATHA SYRINGE SYRINGE N PA Document  
evolocumab REPATHA PUSHTRONEX WEAR INJCT N PA Document  
ezetimibe EZETIMIBE TABLET N    
ezetimibe ZETIA TABLET N    
fenofibrate FENOFIBRATE CAPSULE N    
fenofibrate LIPOFEN CAPSULE N    
fenofibrate FENOGLIDE TABLET N    
fenofibrate nanocrystallized FENOFIBRATE TABLET N    
fenofibrate nanocrystallized TRIGLIDE TABLET N    
fenofibrate nanocrystallized TRICOR TABLET N    
fenofibrate,micronized ANTARA CAPSULE N    
fenofibrate,micronized FENOFIBRATE CAPSULE N    
fenofibric acid FENOFIBRIC ACID TABLET N    
fenofibric acid FIBRICOR TABLET N    
fenofibric acid (choline) FENOFIBRIC ACID CAPSULE DR N    
fenofibric acid (choline) TRILIPIX CAPSULE DR N    
icosapent ethyl VASCEPA CAPSULE N PA Document  
lomitapide mesylate JUXTAPID CAPSULE N PA Document Jul 25, 2013
mipomersen sodium KYNAMRO SYRINGE N PA Document  
niacin NIACIN CAPSULE ER N    
niacin NIASPAN TAB ER 24H N    
niacin NIACIN ER TAB ER 24H N    
omega-3 acid ethyl esters OMEGA-3 ACID ETHYL ESTERS CAPSULE N PA Document  
omega-3 acid ethyl esters LOVAZA CAPSULE N PA Document