ACE Inhibitors - Special Authority Criteria

Generic Name
perindopril

Criteria Approval Period
1. Treatment failure or intolerance to captopril, cilazapril, quinapril, ramipril, or trandolapril.

OR

2. Person identified with a diagnosis of a co-existing disease, e.g., asthma, diabetes or heart disease.

 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Combination product is not eligible for coverage.

Online Forms (PDF)
Click on the link to complete a special authority request form.