Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
zopiclone

Criteria Approval Period
1. Treatment of insomnia
PLUS
diagnosis of HIV/AIDS.

OR

2. Treatment of insomnia
PLUS
person with identified psychiatric diagnosis.

OR

3. Treatment of insomnia
PLUS
person intolerant to, or failed on, at least three specified benzodiazepines.

OR

4. Treatment of insomnia
PLUS
person intolerant to, or failed on, at least two identified benzodiazepines and one other specified hypnotic agent.

OR

5. Treatment of insomnia
PLUS
person with a history of drug or alcohol addiction.

OR

6. Treatment of insomnia
PLUS
fragile, elderly patient.

 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Criteria applicable for all plans including Plan G.

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