Limited Coverage Drugs – Clopidogrel

Generic Name / Strength / Form

clopidogrel

Special Authority Criteria

Approval Period

To be taken in combination with ASA after revascularization with Percutaneous Coronary Intervention (PCI) Up to 12 months
OR
To be taken in combination with ASA for high-risk1, medically-treated patients following hospital-diagnosed unstable angina (UA) or non-ST elevation myocardial infarction (NSTEMI) Up to 12 months
OR

To be taken for the secondary prevention of coronary, cerebral and peripheral vascular occlusion and embolization where a person has experienced treatment failure or intolerance to optimal ASA therapy.

Notes:

  1. High-risk patients are those who have: a history of arterial disease; or a recurrent vascular event while on ASA only or within the initial 30 days of taking clopidogrel plus ASA; or a contraindication to, or a pattern of, coronary artery disease not amenable to revascularization via PCI.
Indefinite

Practitioner Exemptions

  • Cardiologists are invited to enter into a Collaborative Prescribing Agreement (CPA) to permit exemption from completing Special Authority requests for clopidogrel when prescribed according to PharmaCare’s coverage criteria. To ensure uninterrupted coverage for patients, cardiologists who sign a CPA must write prescriptions for clopidogrel for the full intended duration of therapy (e.g., up to 12 months).
  • Prescriptions written by others who have not entered into a CPA will not be covered automatically.

Special Notes

  • A history of arterial disease is defined as previous transient ischemic attack (TIA), stroke or symptomatic peripheral artery disease.
  • Clinical judgment is warranted to assess the increased bleeding risk of combining clopidogrel plus ASA and/or oral anticoagulants.

Special Authority Request Form(s)