Zetia (ezetimibe) — Blue Cross Blue Shield of Alabama
mixed hyperlipidemia
Preferred products
- statin
- statin-niacin combination
- fenofibrate product
Initial criteria
- Approval when ANY ONE of the following is met:
- • The patient has a diagnosis of homozygous sitosterolemia
- OR
- • The patient’s diagnosis is mixed hyperlipidemia AND the patient’s medication history includes use of a fenofibrate product in the past 90 days
- OR
- • The patient’s medication history includes use of a statin or statin-niacin combination in the past 90 days
- OR
- • There is documentation that the patient is currently receiving Zetia (ezetimibe)
- OR
- • The prescriber states the patient is using Zetia (ezetimibe) AND is at risk if therapy is changed
- OR
- • The patient has a history of a documented intolerance, FDA labeled contraindication, or hypersensitivity to a statin or statin-niacin combination
Approval duration
12 months