Limited coverage criteria – hydroxyzine

Last updated on March 27, 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	hydroxyzine
Strength & form	10 mg, 25 mg, 50 mg capsule

Special Authority criteria	Approval period
For the treatment of anxiety	Indefinite

Practitioner exemptions

No practitioner exemptions

Special notes

Criteria applicable to all plans, including Plan G

Special Authority request form(s)

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

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Limited coverage criteria – hydroxyzine

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)