Limited Coverage Drugs - Dipyridamole-acetylsalicylic acid

Generic Name / Strength / Form

Dipyridamole-acetylsalicylic acid

Special Authority Criteria

Approval Period

For secondary prevention of cerebrovascular occlusion and embolization in patients who have experienced recurrent TIA or stroke while receiving ASA alone. Indefinite

Practitioner Exemptions

  • No practitioner exceptions

Special Notes

  • None

Special Authority Request Form(s)