Limited Coverage Drugs - Dipyridamole-acetylsalicylic acid

Generic Name

dipyridamole-acetylsalicylic acid

Strength



dipyridamole + acetylsalicylic acid combination 200/25 mg
(there is 200 mg of dipyridamole and 25 mg of ASA)

 

Form

tablet

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)