Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
benzydamine rinse

Criteria Approval Period
1. For treatment of mucositis, ulcerative complications of chemotherapy.

OR

2. Immunocompromised patients at risk of mucosal breakdown.

 First approval: One year

Renewals: One year

Practitioner Exemptions

  • Oncologist (medical)
  • Oncologist (radiation)

Special Notes

  • None

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