Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
cyclosporine

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

OR

2. Specified diagnosis of severe ocular inflammatory disease prescribed by an ophthamologist 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.

    OR

    4. Psoriasis of the palms and/or soles severe enough to interfere with daily living or work
    PLUS
    treatment failure on topical corticosteroids.

    OR

    5. Nephrotic syndrome.

    		•  Indefinite

    Practitioner Exemptions

    • No practitioner exemptions

    Special Notes

    • * For (1) and (2), see the Cyclosporine / Leflunomide for Rheumatoid Arthritis special authority form for full criteria listing.

    Cylosporine / Leflunomide for Rheumatoid Arthritis Online Form (PDF)
    Click on the link to complete a special authority request form.

    Online Forms (PDF)
    Click on the link to complete a special authority request form.