Limited coverage criteria – fentanyl (tablet)
Last updated on March 17, 2025
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Generic name |
fentanyl |
|---|---|
Strength & form |
100 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg buccal tablet |
Special Authority criteria |
Approval period |
|---|---|
|
The patient uses non-prescribed opioids, is at risk of harm from the toxic street drug supply, and is not fentanyl-naive |
Initial: 1 year Renewals: 1 year |
Practitioner exemptions
- None
Special notes
- Renewal requests should provide update on patient’s current dose and condition
- Criteria applicable to all plans, including Plan G
Special Authority request form(s)