Limited coverage criteria – propranolol hydrochloride

Last updated on March 21, 2025

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Generic name	propranolol hydrochloride
Strength & form	3.75 mg/mL oral solution

Special Authority criteria	Approval period
Initial For the treatment of proliferating infantile¹ hemangioma requiring systemic therapy when: Patient has life- or function-threatening hemangioma OR Patient has ulcerated hemangioma with pain or a lack of response to wound-care measures OR Patient’s hemangioma presents a risk of permanent scarring or disfigurement	6 months
Renewal For the continued treatment of proliferating infantile hemangioma, when the patient has had an incomplete² response to a 6-month course of treatment with propranolol oral solution	6 months³

Special Authority criteria

Approval period

Initial

For the treatment of proliferating infantile¹ hemangioma requiring systemic therapy when:

Patient has life- or function-threatening hemangioma

OR

Patient has ulcerated hemangioma with pain or a lack of response to wound-care measures

Patient’s hemangioma presents a risk of permanent scarring or disfigurement

6 months

Renewal

For the continued treatment of proliferating infantile hemangioma, when the patient has had an incomplete² response to a 6-month course of treatment with propranolol oral solution

6 months³

Special notes

¹PharmaCare considers coverage of infants for initial coverage up to 5 months of age. The age for treatment initiation will be corrected in cases of prematurity
²The prescriber must provide details of the patient’s response versus pre-treatment baseline
³PharmaCare provides a maximum of 2 years total coverage

Practitioner exemptions

No practitioner exemptions

Special Authority request form(s)

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

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