Angiotensin converting enzyme inhibitors – lisinopril

Generic name		lisinopril, including in combination with hydrochlorothiazide
Strength		5 mg, 10 mg, 20 mg, 10 mg/12.5 mg, 20 mg/12.5 mg, 20 mg/25 mg
Form		tablet

Criteria	Approval period
Treatment failure on optimal doses of, or intolerance to, ramipril. OR   Complex patient requiring medications for co-existing chronic condition(s).	Indefinite

Practitioner exemptions

Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:

• Paediatric cardiology
• Paediatrics 

Special notes

• Individuals requiring a diuretic combination product must satisfy the same criteria.
• Patients with co-existing chronic conditions requiring use of multiple medications will be considered complex for the purposes of Special Authority criteria.

Special Authority request form(s)

• Log in to eForms​
• 5328—General Special Authority Request