lisinopril - ACE-I

 

Return to Special Authority drug list 

Generic name		lisinopril, including in combination with hydrochlorothiazide
Strength & form		5 mg, 10 mg, 20 mg, 10 mg/12.5 mg, 20 mg/12.5 mg, 20 mg/25 mg tablet

Special Authority 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:

• Pediatric cardiology
• Pediatrics 

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)

• Log in to eForms​
• HLTH 5328 – General Special Authority request (PDF, 656KB)