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) QUESTRAN POWDER Y    
CHOLESTYRAMINE (WITH SUGAR) CHOLESTYRAMINE POWDER Y    
CHOLESTYRAMINE/ASPARTAME PREVALITE POWD PACK Y    
CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT POWD PACK Y    
CHOLESTYRAMINE/ASPARTAME QUESTRAN LIGHT POWDER Y    
CHOLESTYRAMINE/ASPARTAME PREVALITE POWDER Y    
CHOLESTYRAMINE/ASPARTAME CHOLESTYRAMINE LIGHT POWDER Y    
FENOFIBRATE FENOFIBRATE TABLET Y 120 mg, 40 mg Require PA  
GEMFIBROZIL LOPID TABLET Y    
GEMFIBROZIL GEMFIBROZIL TABLET Y    
ALIROCUMAB PRALUENT PEN PEN INJCTR N PA Document  
COLESEVELAM HCL WELCHOL POWD PACK N    
COLESEVELAM HCL WELCHOL 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    
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 TRIGLIDE TABLET N    
FENOFIBRATE NANOCRYSTALLIZED TRICOR TABLET N    
FENOFIBRATE NANOCRYSTALLIZED FENOFIBRATE TABLET N    
FENOFIBRATE,MICRONIZED FENOFIBRATE CAPSULE N    
FENOFIBRATE,MICRONIZED ANTARA CAPSULE N    
FENOFIBRIC ACID FENOFIBRIC ACID 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    
NIACIN NIACOR TABLET 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