Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
gliclazide (80mg regular release tablet and 30mg modified release tablet)

Criteria Approval Period
Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses. Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • none

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