Limited coverage drugs – baclofen intrathecal
Last updated on October 7, 2022
|
Generic name |
baclofen intrathecal |
|---|---|
|
Strength |
0.05 mg/ml, 500 mcg/ml, 2 mg/ml |
| Form |
ampul |
|
Special Authority criteria |
Approval period |
|---|---|
|
Diagnosis of severe spasticity due to multiple sclerosis PLUS treatment failure or intolerance to oral medication and physical therapy PLUS exclusion of noxious stimuli as a major contributing cause to the spasticity |
Indefinite |
|
Diagnosis of severe spasticity due to spinal cord injury PLUS at least one year has passed since the spinal cord injury occurred PLUS treatment failure or intolerance to oral medication and physical therapy PLUS exclusion of noxious stimuli as a major contributing cause to the spasticity |
Indefinite |
Practitioner exemptions
- None
Special notes
- None