Limited Coverage Drugs - ticlopidine

Generic Name / Strength / Form

ticlopidine

Criteria

Approval Period

In secondary prevention of coronary, cerebral and peripheral vascular occlusion and embolization where patient has experienced failure or intolerance to ASA. Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)

Online Forms (PDF, 523KB)
Click on the link to complete a special authority request form.