Generic Name / Strength / Form

rosiglitazone 2mg, 4mg and 8mg

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.
• Individuals requiring a metformin combination product must satisfy the same criteria.
• 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