Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
propoxyphene

Criteria Approval Period
Pain management in a specified pain diagnosis*
PLUS
Treatment failure or intolerance to at least two identified opioids. 		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.
  • Renewals requests should provide update on patient’s current dose and condition.

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