Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
codeine sustained release

Criteria Approval Period
1. Diagnosis of cancer
PLUS
patients who are unable to tolerate or receive an adequate response to the regular dosage forms of codeine. 		1. First approval: One year

Renewals: One year
OR
2. Pain management in a specified chronic pain diagnosis*
PLUS
patients who are unable to tolerate or receive an adequate response to the regular dosage forms of codeine.		 2. First approval: One year

Renewals: One year

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • *Details regarding patient's condition and previous medication history are required.
  • Renewal requests should provide update on patient’s current dose and condition.
  • Codeine SR is a full benefit for patients registered with the Palliative program.

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