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Limited Coverage Drugs - Special Authority Criteria
| Generic Name / Strength / Form |
| pioglitazone 15mg, 30mg and 45mg |
| 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: 26 week supply
Renewal: 1 year |
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.
- 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 - Initial Coverage (26 Week Supply) (PDF)
Pioglitazone / Rosiglitazone - Renewal of PharmaCare Coverage (PDF)
PDF Format
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Last Revised: January 22, 2008
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