Special Authority Criteria - Clopidogrel

Generic Name / Strength / Form

clopidogrel

Criteria	Approval Period
1. In secondary prevention of coronary, cerebral and peripheral vascular occlusion and embolization where a person has experienced treatment failure or intolerance to ASA.	1. Indefinite
OR
2. Documented post-Percutaneous Coronary Intervention.	2. Thirty days
OR
3. Documented post-stent procedure with Drug Eluting Stent.	3. Up to twelve months
OR
4.For high-risk, medically-treated patients following hospital-diagnosed Acute Coronary Syndrome in combination with ASA. High-risk patients are those who have: a history of arterial disease; OR a recurrent vascular event while on ASA alone or within the initial 30 days of combination clopidogrel plus ASA; OR a contraindication to, or a pattern of, coronary artery disease not amenable to mechanical revascularization. Notes: Acute Coronary Syndrome (ACS) is defined as unstable angina or non-ST elevation myocardial infarction. A history of arterial disease is defined as previous transient ischemic attack (TIA), stroke, or symptomatic peripheral artery disease. Clinical judgment is warranted to assess the increased bleeding risk of combining clopidogrel with ASA and/or oral anticoagulants.	4. Up to twelve months