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Limited Coverage Drugs - Special Authority Criteria
| Generic Name / Strength / Form |
| propoxyphene |
| Criteria |
Approval Period |
Pain management in a specified pain diagnosis*
PLUS
Treatment failure or intolerance to at least two identified opioids.
|
First approval: One year Renewals: One year |
Practitioner Exemptions
- No practitioner exemptions
Special Notes
- Details regarding patient's condition and previous medication history are required.
- Renewals requests should provide update on patient’s current dose and condition.
Online Forms (PDF)
Click on the link to complete a special authority request form.
PDF Format
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Last Revised: April 20, 2007
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