Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

indapamide

Criteria

Approval Period

Treatment failure or intolerance to a thiazide diuretic.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)

Online Form (PDF, 524KB)
Click on the link to complete a special authority request form.