Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
insulin glargine
Criteria Approval Period

Type 1 diabetes – Patient of any age

Patient has a diagnosis of Type 1 diabetes requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing:

OR

Type 2 diabetes – Patients over 17 years of age only

Patient has a diagnosis of Type 2 diabetes requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing:

AND

  1. Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management.

OR

  1. Has documented severe or continuing systemic or local allergic reaction to existing insulin (see Special Notes below).
 Indefinite

Practitioner Exemptions

  • Endocrinologists

Special Notes

  • Specialists with experience in paediatric diabetes management may also have prescriptions covered for patients meeting the coverage criteria but are required to submit a Special Authority request.
  • For item #2 above, documentation of previous trials (i.e., specific insulin tried and patient's response) is required.

Special Authority Form

Click on the link below to complete the Special Authority request form.

Online Form (PDF)