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)
- General Special Authority request (PDF, 523KB)