Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
tizanidine

Criteria Approval Period
Diagnosis of spasticity
PLUS
documented evidence of treatment failure or intolerance to diazepam or baclofen.		 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

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