Limited coverage criteria – famotidine

Generic name	famotidine
Strength & form	20 mg and 40 mg tablet

Special Authority criteria	Approval period
Treatment failure on prescription dose of, or intolerance to, ranitidine	Indefinite

Practitioner exemptions

• Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:
  • Pediatrics
  • Pediatric cardiology
  • Pediatric general surgery

Special notes

• Prescription dose of ranitidine for adults is considered to be 150 mg twice daily or 300 mg once daily
• Non-prescription use of famotidine is not eligible for PharmaCare coverage

Special Authority request form

• Log in to eForms
• HLTH 5328 - General Special Authority request (PDF, 656KB)