Limited Coverage Drugs - Codeine sustained release

Generic Name / Strength / Form

codeine sustained release

Special Authority Criteria

Approval Period
1. Diagnosis of cancer
PLUS
patients who are unable to tolerate or receive an adequate response to the regular dosage forms of codeine.

1. First approval: One year

Renewals: One year
OR
2. Pain management in a specified chronic pain diagnosis*
PLUS
patients who are unable to tolerate or receive an adequate response to the regular dosage forms of codeine.

2. First approval: One year

Renewals: One year

Practitioner Exemptions

  • No practitioner exceptions

Special Notes

  • *Details regarding patient's condition and previous medication history are required.
  • Renewal requests should provide update on patient’s current dose and condition.
  • Codeine SR is a full benefit for patients registered with the Palliative program.

Special Authority Request Form(s)