Limited coverage criteria – cyclosporine

 

Return to Special Authority drug list 

Generic name	cyclosporine
Strength and form	10 mg, 25 mg, 50 mg, 100 mg capsule

Special Authority criteria	Approval period
For the treatment of rheumatoid arthritis when a Special Authority request is submitted by a rheumatologist	Indefinite
For the treatment of severe ocular inflammatory disease when a Special Authority request is submitted by an ophthalmologist or rheumatologist
Extensive psoriasis involving at least 25% of body surface or having psoriasis area and severity index of at least 12 when ALL of the following criteria are met: Special Authority request is submitted by a dermatologist or rheumatologist AND Patient has treatment failure of: Topical therapy with corticosteroids; and Ultraviolet-B light or oral or topical methoxsalen plus ultraviolet-A light
Psoriasis of the palms and/or soles severe enough to interfere with daily living or work when: Special Authority request is submitted by a dermatologist AND Patient has treatment failure on topical corticosteroids
For the treatment of nephrotic syndrome when a Special Authority request is submitted by a nephrologist

Practitioner exemptions

• Prescriptions for oral cyclosporine written by an exempted prescriber are eligible for PharmaCare coverage without submission of a Special Authority request. No Special Authority record will be created on the PharmaNet system
• For any patient who does not meet the limited coverage criteria, a practitioner with an exemption is required to do one of the following:
  1. Write on the prescription “Submit as zero cost to PharmaCare”, to indicate to the pharmacist that the prescription is not to be covered by PharmaCare; OR
  2. Apply for exceptional PharmaCare coverage by submitting a Special Authority request with full documentation (via fax to 1 800-609-4884). Special Authority requests are subject to review by PharmaCare and will not be covered automatically. If PharmaCare coverage is denied the practitioner must write on the prescription “Submit as zero cost to PharmaCare”

Special notes

• Special Authority requests for the treatment of moderate to severe atopic dermatitis will be considered on a case-by-case basis when coverage is requested by a dermatologist, allergist, or clinical immunologist
• Special Authority requests for the treatment of patients 18 years of age and older with active, autobody positive moderate to severe systemic lupus erythematosus (SLE) will be considered on a case-by-case basis when coverage is requested by a rheumatologist or dermatologist

Special Authority request form(s)

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