Limited coverage criteria – gliclazide

Last updated on March 18, 2025

Special Authority requests can now be submitted online. It's simple and quick!

This drug is eligible for automatic approval when patient meets criteria and the request is submitted by eForms.

Generic name	gliclazide
Strength & form	30 mg, 60 mg modified-release tablet 80 mg tablet

Special Authority criteria	Approval period
For the treatment of type 2 diabetes, when the patient has demonstrated treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses	Indefinite

Practitioner exemptions

No practitioner exemptions

Special notes

Gliclazide is a regular benefit for Plan W (First Nations Health Benefits) recipients

Special Authority request form(s)

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

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Limited coverage criteria – gliclazide

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)