Limited Coverage Drugs - Zopiclone

Generic Name / Strength / Form

zopiclone

Special Authority Criteria

Approval Period

1. Treatment of insomnia

PLUS

diagnosis of HIV/AIDS.

OR

2. Treatment of insomnia

PLUS

person with identified psychiatric diagnosis.

OR

3. Treatment of insomnia

PLUS

person intolerant to, or failed on, at least three specified benzodiazepines.

OR

4. Treatment of insomnia

PLUS

person intolerant to, or failed on, at least two identified benzodiazepines and one other specified hypnotic agent.

OR

5. Treatment of insomnia

PLUS

person with a history of drug or alcohol addiction.

OR

6. Treatment of insomnia

PLUS

fragile, elderly patient.

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • Criteria applicable for all plans, including Plan G

Special Authority Request Form(s)