Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form



Approval Period

Pain management in a specified pain diagnosis*
Treatment failure or intolerance to at least two identified opioids.

First approval: One year

Renewals: One year

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • *Details regarding patient's condition and previous medication history are required.
  • Renewals requests should provide update on patient’s current dose and condition.

Special Authority Request Form(s)

Online Forms (PDF, 523KB)
Click on the link to complete a special authority request form.