Limited coverage drugs – hydroxyzine

Last updated on August 27, 2024

Special Authority requests can now be submitted online. It's simple and quick!

This drug is eligible for automatic approval when patient meets criteria and the request is submitted by eForms.

Generic name	hydroxyzine
Strength	10 mg, 25 mg, 50 mg
Form	capsule

Criteria	Approval period
For the treatment of anxiety.	Indefinite

Practitioner exemptions

No practitioner exemptions

Special notes

Criteria applicable to all plans including Plan G

Special Authority request form(s)

Log in to eForms
HLTH 5328 - Special Authority Request (PDF, 656KB)

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Limited coverage drugs – hydroxyzine

Practitioner exemptions

Special notes

Special Authority request form(s)