Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
rosiglitazone 2mg, 4mg and 8mg

Criteria Approval Period
For treatment of Type II diabetes in patients who have experienced:

Failure of, or intolerance to, metformin
PLUS
Failure of, or intolerance to, glyburide
OR
For patients intolerant to glyburide: failure of, or intolerance to, gliclazide or another sulfonylurea drug.

 First approval: indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Coverage is not available for patients who are using insulin or who have certain other medical conditions (please refer to the initial coverage form for details).
  • Coverage available for patients on all plans except Plan D and Plan G.
  • Individuals requiring a metformin combination product must satisfy the same criteria.
  • All requests must be completed and submitted on the forms below.

Special Authority Forms

Click on the appropriate Special Authority Form below for full criteria:

Pioglitazone / Rosiglitazone (PDF)