Limited Coverage Drugs – Benzydamine

Generic Name

benzydamine

Strength

oral rinse
Form 0.15 % mouthwash

Special Authority Criteria

Approval Period

1. For treatment of mucositis, ulcerative complications of chemotherapy.

OR

2. Immunocompromised patients at risk of mucosal breakdown.

First approval: One year

Renewals: One year

Practitioner Exemptions

  • Oncologist (medical)
  • Oncologist (radiation)

Special Notes

  • None

Special Authority Request Form(s)