Limited coverage drugs – sacubitril-valsartan
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Generic name |
sacubitril-valsartan |
|
---|---|---|
Strength |
24 mg/26 mg, 49 mg/51 mg, 97 mg/103 mg |
|
Form |
tablets |
Special Authority criteria |
Approval period |
---|---|
For the treatment of heart failure (HF) with reduced ejection fraction in patients with New York Heart Association (NYHA) class II or III HF, if all the following clinical criteria are met:
AND
Notes:
|
Indefinite |
Practitioner exemptions
- None
Special notes
- None
Special Authority requests
Requests should be completed by a cardiologist or an internal medicine specialist.
- Log in to eForms
- HLTH 5484 - Sacubitril-Valsartan Combination Special Authority Request (PDF, 301KB)