Ezetimibe is a safe and effective medication for achieving secondary prevention low-density lipoprotein-cholesterol (LDL-C) targets after acute coronary syndrome (ACS). We sought to examine ezetimibe prescribing after ACS and the effects of expanding the Australian Pharmaceutical Benefits Scheme eligibility criteria. A retrospective analysis was performed for the rates and factors of ezetimibe eligibility and prescribing in ezetimibe-naive patients with ACS admitted to a single quaternary centre between May 2020 and September 2022. Eligibility rates were also assessed with tighter LDL-C targets and with modelling to identify patients unlikely to achieve targets with first-line care. Of 757 patients with ACS with LDL-C >1.8 mmol/L, 94 were eligible for ezetimibe. This subgroup was highly comorbid but only 16 patients were prescribed ezetimibe. The univariate logistic regression identified statin contraindication (odds ratio 19.4; 95% confidence interval 4.58-103.9; p<0.001) and higher LDL-C (odds ratio 2.43 per 1 mmol/L; 95% confidence interval 1.44-4.67; p=0.03) as key predictors of prescribing. Of 956 patients with ACS with an LDL-C >1.4 mmol/L, tightening LDL-C targets from 1.8 to 1.4 mmol/L increased eligibility from 94 (9.8%) to 152 (16.0%) patients, whereas predictive modelling substantially expanded eligibility to 309 (32.3%) and 620 (64.9%) with the 1.8 mmol/L and 1.4 mmol/L targets, respectively. In the acute setting after ACS, Australian Pharmaceutical Benefits Scheme restrictions limit ezetimibe to highly comorbid patients with a high risk of recurrent disease. Despite this, the prescribing rates were poor. Furthermore, a larger group of patients are discharged on treatments that are unlikely to achieve guideline-directed LDL-C targets. Rationalising eligibility criteria for ezetimibe would likely improve access to early and effective secondary prevention.