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Limited Coverage Drugs - Special Authority Criteria
| Generic Name / Strength / Form |
| gliclazide 80mg |
| Criteria |
Approval Period |
| Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses. |
Indefinite |
Practitioner Exemptions
- No practitioner exemptions
Special Notes
- Coverage for gliclazide modified-release 30 mg tablets is also available through Special Authority but subject to the current Low Cost Alternative price for gliclazide 80mg. Patients are required to pay the difference in cost.
Online Forms (PDF)
Click on the link to complete a special authority request form.
PDF Format
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Last Revised: June 21, 2006
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