WHA
 

Fibric Acid Derivatives

Indications for Prior Authorization

Fenoglide, Fibricor
  • For diagnosis of Primary Hyperlipidemia
    Indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), in adults patients with primary hyperlipidemia when use of recommended LDL-C lowering therapy is not possible.

  • For diagnosis of Severe Hypertriglyceridemia
    Indicated as adjunctive therapy to diet to reduce triglyceride (TG) levels in adults with severe hypertriglyceridemia (TG greater than or equal to 500 mg/dL).

    Limitations of Use: Markedly elevated levels of serum triglycerides (e.g., > 2000 mg/dL) may increase the risk of developing pancreatitis. The effect of fenofibrate therapy on reducing this risk has not been adequately studied.

    Fenofibrate did not reduce coronary heart disease morbidity and mortality in two large, randomized controlled trials of patients with type 2 diabetes mellitus.

Criteria

Brand Fenoglide, Brand Fibricor

Step Therapy

Length of Approval: When approved; no reauthorization required

  • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
    • AND
  • Trial and failure (of a minimum 30 day supply) or intolerance to both of the following:
    • One of the following generics:
      • fenofibrate micronized capsule
      • fenofibrate tablet
      • fenofibric capsule
      • fenofibric acid tablet
      AND
    • One of the following:
      • Brand Lipofen
      • Generic fenofibrate capsule

  • Guideline ID
    GL-557211

  • Formulary
    premium

  • Effective date
    Jun 1, 2026

  • P&T approval date

P & T Revisions

2026-03-31, 2025-12-18, 2025-12-18, 2025-05-29, 2025-03-24, 2024-04-02, 2023-09-06, 2023-01-04, 2022-09-01, 2021-09-01, 2020-08-18, 2019-09-05

  1. Fenoglide Prescribing Information. Salix Pharmaceuticals. Bridgewater, NJ. June 2021.
  2. Fibricor Prescribing Information. Athena Bioscience, LLC. Athena, GA. December 2020.
  3. Blumenthal, R, Morris, P, Gaudino, M. et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. JACC. null2026, 0 (0) https://doi.org/10.1016/j.jacc.2025.11.016.
  • 2026-03-31: 2026 Annual Review. Removal of EHB from guideline. Indications updated in line with current FDA label.
  • 2025-12-18: No criteria change, bulk copy oRX-EHB
  • 2025-12-18: no criteria changes, added IL statute operational note
  • 2025-05-29: Removing reauthorization requirement as part of extended reauthorization program.
  • 2025-03-24: 2025 Annual Review. Updated trial and failure language to standard format.
  • 2024-04-02: Annual Review - No criteria changes
  • 2023-09-06: Annual Review - No criteria changes
  • 2023-01-04: Triglide will be removed as target drug as product obsolete. ST criteria for Fenoglide and Fibricor will be updated to include generic Lipofen as an additional trial option.
  • 2022-09-01: 2022 Annual Review - Update to add criteria "Requested drug is being used for a Food and Drug Administration (FDA)-approved indication"
  • 2021-09-01: Annual review: Updated attached target drugs and background.
  • 2020-08-18: Updated criteria to indicate 30 day supply trial of maintenance drugs.
  • 2019-09-05: Guideline updated