Special Authority Criteria - Cyclosporine

Generic Name / Strength / Form
cyclosporine

Criteria Approval Period
1. Diagnosis of rheumatoid arthritis AND prescribed by a rheumatologist. 

OR

2. Severe ocular inflammatory disease AND prescribed by an ophthalmologist or rheumatologist. 

OR

3. Extensive psoriasis involving at least 25% of body surface or having psoriasis area and severity index of at least 12

PLUS

treatment failure of the following:
(a) topical therapy with corticosteroids; and
(b) ultraviolet-B light or oral or topical methoxsalen plus ultraviolet-A light

AND prescribed by a dermatologist or rheumatologist.

OR

4. Psoriasis of the palms and/or soles severe enough to interfere with daily living or work

PLUS

treatment failure on topical corticosteroids AND prescribed by a dermatologist.

OR

5. Nephrotic syndrome AND prescribed by a nephrologist.

 Indefinite

Practitioner Exemptions

Dermatologists, nephrologists, ophthalmologists and rheumatologists.

  • Exempted Specialists who prescribe cyclosporine for patients who do NOT meet any of the established criteria noted above,are instructed to either write on the prescription “Submit as zero cost to PharmaCare” to ensure appropriate PharmaCare coverage, OR, may submit a Special Authority request for exceptional coverage consideration.

Special Notes

None.