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Limited coverage drugs – vancomycin

Last updated on September 27, 2024

Generic name

vancomycin

Strength

125 mg, 250 mg

Form

capsule

Special Authority criteria

Approval period

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

  1. The patient is allergic, resistant or intolerant to metronidazole.
    OR
  2. The patient has failed to respond to 4 to 6 days of oral metronidazole at doses of 500 mg three times per day.
    OR
  3. The patient has symptoms of moderate to severe disease or is experiencing a second disease recurrencei
    OR
  4. 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

  1. Recurrence is defined as a subsequent CDI episode occurring within 2 to 8 weeks of the date of diagnosis of a previous episode.
  2. Vancomycin capsules are a full benefit for patients registered with the PharmaCare Palliative Care Drug Plan (Plan P).
  3. 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).
  4. 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 PharmaNet Help Desk (available 24 hours a day, 7 days a week) 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 webpage.

Special Authority requests​