Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
ticlopidine

Criteria Approval Period
In secondary prevention of coronary, cerebral and peripheral vascular occlusion and embolization where patient has experienced failure or intolerance to ASA. Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

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