Prior authorization drugs
All drugs with prior authorization status require pre-approval. Prescribers should review the reimbursement criteria below and submit a report demonstrating the criteria are met. You can upload the report right to the claim file using our website.
Drug name | Brands reimbursed | Dosage form/strength | Reimbursement criteria |
---|---|---|---|
Botulinum |
Botox® |
Botox®: Xeomin®: Dysport TherapeuticTM: |
BTX-A may be approved for the following conditions:
Additionally, the injured worker must meet the following criteria:
For neurogenic detrusor overactivity, the following additional criteria must also be met:
For chronic migraine, the following additional criteria must also be met:
*failure defined as <30% reduction in frequency of headache days to an adequate dose and duration of 3 prophylactic therapies (2 treatments must be of different classes, and contraindications or intolerable adverse effects considered for only 1 of 3 medications) Notes regarding continued therapy with Botox® for chronic migraine prophylaxis:
Criteria for resumption of Botox® for chronic migraine prophylaxis (Renewal Criteria):
Duration of authorization is determined on a case-by-case basis. |
Buprenorphine / Naloxone |
*Suboxone® + generics |
2 mg/0.5 mg |
Buprenorphine / Naloxone may be approved for:
Duration of authorization is determined on case-by-case basis. |
Diclofenac |
*Pennsaid® + generics |
1.5% w/w in solution |
Diclofenac sodium solution may be approved if all of the following conditions are met:
|
Diclofenac diethylamine |
Voltaren® Emulgel Voltaren® Emulgel Joint Pain Voltaren® Emulgel Extra Strength |
1.16% w/w |
Diclofenac diethylamine may be approved for treatment if all of the following conditions are met:
|
Tramadol |
Short-acting: Ultram® and generics
Long-acting: |
Tramadol 37.5mg/Acetaminophen 325mg tablets Tramadol 50mg tablets
Tramadol 100mg, 200mg, 300mg ER tablets |
Tramadol may be approved in the following situations:
Duration of authorization is determined on a case-by-case basis. Renewal will be granted if objective evidence supports improvement in pain and function. |
*If an interchangeable generic product is available, the brand product will only be funded if medically necessary.
If the desired drug is not included in the table, we follow the criteria and administration guidelines suggested by the Ontario Drug Benefit programs and Cancer Care Ontario. For narcotic (opioid) medications that require prior authorization, please consult our Opioids at the WSIB page.
People with a workplace injury or illness who are registered for online services can view their entitlement for prior authorization status medication in the Health Care - Medication section.
Non-formulary drugs
Requests for medications that are not found in the drug benefit program formulary search may be considered for coverage on a case-by-case basis.
Prescribers applying for coverage of a non-formulary medication under exceptional use must submit a report with the following information:
- diagnosis,
- reasons why formulary-listed alternatives may not be appropriate
- current/previous medications tried
- outcomes
- any other relevant medications or illnesses
If the patient is currently taking the requested medication please indicate the start date and objective evidence of efficacy. You can upload the report right to the claim file using our website.
People with a workplace injury or illness who are registered for online services can view their entitlement for non-formulary drug medication in the Health Care - Medication section.