Limited coverage criteria – codeine controlled release

Last updated on March 17, 2025

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Generic name	codeine controlled release
Strength & form	50 mg, 100 mg, 150 mg, 200 mg tablet

Special Authority criteria	Approval period
Diagnosis of cancer PLUS Patients who are unable to tolerate or receive an adequate response to the regular dosage forms of codeine	First approval: 1 year Renewals: 1 year
OR
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	First approval: 1 year Renewals: 1 year

Special Authority criteria

Approval period

Diagnosis of cancer

PLUS

Patients who are unable to tolerate or receive an adequate response to the regular dosage forms of codeine

First approval: 1 year

Renewals: 1 year

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

First approval: 1 year

Renewals: 1 year

Practitioner exemptions

None

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)

Log in to eForms
HLTH 5328 – General Special Authority request (PDF, 656KB)

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