Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
budesonide enema

Criteria Approval Period
For treatment of ulcerative colitis
PLUS
treatment failure or intolerance to other commercially available rectal corticosteroid preparations.		 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

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