Limited coverage drugs – baclofen intrathecal

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

Special Authority request form(s)