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

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.