We will consider request for coverage for medications that are not found in the drug benefit program formulary search on a case-by-case basis. For narcotic (opioid) medications, please read about our approach to opioid treatment.
Prior authorization drugs
All drugs with prior authorization status require pre-approval. For prior authorization drugs, the message Authorization required will display at the point of sale
Prescribers should review the prior-authorization criteria below. If the desired drug is not included in the table, we follow the criteria and administration guidelines suggested by the Ontario Drug Benefit programs, Cancer Care Ontario and Canadian Agency for Drugs and Technologies in Health (CADTH).
The prior-authorization criteria for originator biologic drug and biosimilar biologic drug are equivalent for the same indications; however, biosimilar will be preferentially funded, based on advice from our Drug Advisory Committee, as is the case with the Ontario Drug Benefit programs and the Cancer Care Ontario. We can consider requests for exceptions from the prescriber in rare situations.
Prescribers applying for coverage of a non-formulary or prior-authorization medication must submit a report with the following information:
- Rationale for requesting drug
- Dose and duration of treatment
- Diagnoses and comorbidities. Please include as much detail as possible about type, stage of illness and severity of presentation
- Reasons why formulary-listed alternatives may not be appropriate
- Current/previous medications tried, or outcome of previous failed medication trials with exact timelines, including detailed regimens, attempted dose escalations and subsequent outcome evaluation
- Pertinent laboratory results, imaging and medical status information (e.g., Eastern Cooperative Oncology Group (ECOG) score, CT results, etc.)
- Supporting applicable literature evaluating use of the requested medication and/or regimen (non-formulary drugs)
- Other applicable information
BTX-A may be approved for the following conditions:
Additionally, the injured person must meet the following criteria:
*Beta-blockers, TCAs, verapamil/flunarizine, sodium valproate/divalproex sodium, topiramate, gabapentin
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 subdermal implant
80 mg subdermal implant
Buprenorphine Subdermal Implant may be approved for:
Buprenorphine ER injection
100 mg/0.5 mL &
Buprenorphine ER injection may be approved for:
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.
*Pennsaid® + generics
1.5% w/w in solution
Diclofenac sodium solution may be approved if all of the following conditions are met:
Voltaren® Emulgel Joint Pain
Voltaren® Emulgel Extra Strength
Diclofenac diethylamine may be approved for treatment if all of the following conditions are met:
Ultram® and generics
Durela® and generics
Tramadol 37.5mg/Acetaminophen 325mg tablets
Tramadol 50mg tablets
Tramadol 100mg, 200mg, 300mg ER tablets
Tramadol 75mg, 100mg, 150mg, 200mg, 300mg, 400mg XL 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.