Limited Coverage Drugs - Gliclazide

Generic Name / Strength / Form

gliclazide (80mg regular release tablet, and 30mg and 60mg modified release tablet)

Special Authority Criteria

Approval Period

Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses. Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)

Online Forms (PDF, 523KB)
Click on the link to complete a special authority request form.