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
  1. Treatment failure on optimal doses of, or intolerance to, ramipril.

    OR
     
  2. 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)

5328—General Special Authority Request