Limited Coverage Drugs - Acamprosate

Generic Name

  acamprosate

Strength

  333 mg 

Form

  tablet

 

Special Authority Criteria

Approval Period

For the maintenance of abstinence in patients who have been abstinent from alcohol for at least four days OR for the treatment of alcohol use disorder for patients who have contraindications to naltrexone (e.g., concurrent opioid use, acute hepatitis, or liver failure)

AND

in combination with behavioural intervention therapy (e.g., psychosocial counselling) as necessary.

  1 year

 

Practitioner Exemptions

  • PharmaCare coverage will be provided only for a patient who meets the Limited Coverage criteria, and whose prescription is written by a prescriber who has entered into a Collaborative Prescribing Agreement.
  • Due to the individual nature of each Collaborative Prescribing Agreement, the Agreement must be signed by the prescriber and not his/her delegate.

Special Notes

  • The above criteria is applicable for all PharmaCare coverage plans, including the Psychiatric Medications Plan (Plan G).

Special Authority Request Forms

  • Not applicable.