Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

baclofen intrathecal


 

Criteria

Approval Period

1. Diagnosis of severe spasticity due to multiple sclerosis
PLUS
treatment failure or intolerance to oral medication and physical therapy
PLUS
exclusion of noxious stimuli as a major contributing cause to the spasticity.

Indefinite

2. Diagnosis of severe spasticity due to spinal cord injury
PLUS
at least one year has passed since the spinal cord injury occurred
PLUS
treatment failure or intolerance to oral medication and physical therapy
PLUS
exclusion of noxious stimuli as a major contributing cause to the spasticity.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Online Forms (PDF)
Click on the link to complete a special authority request form.