Limited coverage criteria – vancomycin

Last updated on March 24, 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	vancomycin
Strength & form	125 mg, 250 mg capsule

Special Authority criteria	Approval period
For the treatment of symptomatic clostridium difficile infection (CDI), when: The patient is allergic, resistant or intolerant to metronidazole OR The patient has failed to respond to 4 to 6 days of oral metronidazole at doses of 500 mg three times per day OR The patient has symptoms of moderate to severe disease or is experiencing a second disease recurrenceⁱ OR The patient was initiated on vancomycin as an inpatient (e.g., in a hospital setting, nursing home, or long-term care facility) and requires continuation of vancomycin to complete their full course of therapy	Initial: up to 14 days Second or further recurrence: up to 14 days

Special Authority criteria

Approval period

For the treatment of symptomatic clostridium difficile infection (CDI), when:

The patient is allergic, resistant or intolerant to metronidazole

The patient has failed to respond to 4 to 6 days of oral metronidazole at doses of 500 mg three times per day

The patient has symptoms of moderate to severe disease or is experiencing a second disease recurrenceⁱ

The patient was initiated on vancomycin as an inpatient (e.g., in a hospital setting, nursing home, or long-term care facility) and requires continuation of vancomycin to complete their full course of therapy

Initial: up to 14 days

Second or further recurrence: up to 14 days

Practitioner exemptions

None

Special notes

Recurrence is defined as a subsequent CDI episode occurring within 2 to 8 weeks of the date of diagnosis of a previous episode
Vancomycin capsules are a full benefit for patients registered with Plan P (Palliative Care)
Prescribers may submit SA requests at any time. A coverage decision is generally provided within one business day for faxed forms (and may be quicker with eForms)
Urgent Special Authority requests can be made:

If the patient meets any of the criteria. The prescriber can contact the Special Authority line Monday to Friday, 8 am to 4 pm (excluding statutory holidays), to request authorization; or
After hours, if a patient meets any of the criteria. The prescriber can contact the 24/7 PharmaNet Help Desk to request initial urgent coverage for vancomycin. All requests to renew existing coverage must be made through Special Authority via fax or phone during regular business hours
pharmacists may request Special Authority coverage for vancomycin dispensed after a hospital stay. For more information regarding when pharmacists can request Special Authority, refer to Limited coverage drugs

Special Authority requests form(s)

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

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