Limited coverage criteria – felodipine

 

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Generic name	felodipine
Strength & form	2.5 mg, 5 mg, 10 mg extended release tablet

Special Authority criteria	Approval period
Treatment failure on optimal doses of, or intolerance to, amlodipine  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:
  • Cardiologists
  • Cardiovascular and thoracic surgery
  • Internists specializing in cardiology
  • Nephrologists
  • Pediatrics
  • Pediatric cardiology

Special notes

• 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)