Limited coverage criteria - nizatidine

Last updated on March 19, 2025

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Generic name		nizatidine
Strength & form		150 mg/300 mg capsule

Special Authority Criteria	Approval period
Treatment failure on prescription dose¹ of, or intolerance to, ranitidine	Indefinite

Practitioner exemptions

Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:

Pediatric cardiology
Pediatrics
Pediatric general surgery

Special notes

¹Prescription dose of ranitidine for adults is considered to be 150 mg twice daily or 300 mg once daily

Special Authority request form(s)

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HLTH 5328 – General Special Authority request (PDF, 656KB)

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Limited coverage criteria - nizatidine

Generic name

Strength & form

Special Authority Criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)