Limited coverage criteria – dipyridamole-acetylsalicylic acid

Last updated on March 4, 2025

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Generic name	dipyridamole-acetylsalicylic acid
Strength & form	dipyridamole + acetylsalicylic acid combination 200/25 mg tablet (there is 200 mg of dipyridamole and 25 mg of ASA)

Special Authority criteria	Approval period
For secondary prevention of cerebrovascular occlusion and embolization in patients who have experienced recurrent TIA or stroke while receiving ASA alone.	Indefinite

Practitioner exemptions

None

Special notes

None

Special Authority request form(s)

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HLTH 5328 - General Special Authority Request (PDF, 656KB)

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Limited coverage criteria – dipyridamole-acetylsalicylic acid

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)