Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
etanercept

Criteria

Approval Period

1. Treatment of Rheumatoid Arthritis according to established criteria* as prescribed by a rheumatologist

First approval: 1 year
Renewal: 1 year to indefinite

2. Treatment of Psoriatic Arthritis according to established criteria* as prescribed by a rheumatologist

First approval: 1 year
Renewal: 1 year to indefinite

3. Treatment of Ankylosing Spondylitis according to established criteria* as prescribed by a rheumatologist

First approval: 26 weeks
Renewal: 1 year to indefinite

Practitioner Exemptions

  • Pediatric rheumatologists for pediatric patients diagnosed with rheumatoid arthritis

Special Notes

  • Ankylosing Spondylitis coverage became effective March 14, 2008.
  • Coverage for infliximab for psoriatic arthritis became effective March 14, 2008.
  • For coverage, the maximum allowable supply of etanercept is for 28 days per fill.

Forms

* Click on the appropriate Special Authority Form below for full criteria: