Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
infliximab

Criteria

Approval Period

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

First approval: 1 year
Renewal: 1 year to indefinite

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

First approval: 1 year
Renewal: 1 year to indefinite

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

First approval: 1 year
Renewal: 1 year to indefinite

4. Treatment of moderate to severe active Crohn's disease or fistulizing Crohn’s disease according to established criteria* when prescribed by a gastroenterologist.

First approval (induction period): three dose supply
Renewal: 1 year

5. Treatment of moderate to severe psoriasis, according to established criteria*, when prescribed by a dermatologist.

First approval: induction 3 doses
Renewal: 1 year

Practitioner Exemptions

  • Pediatric rheumatologists for pediatric patients diagnosed with rheumatoid arthritis

Special Notes

  • For coverage, the maximum allowable supply of infliximab is 56 days per fill. One infusion (dose) usually provides treatment for 56 days or less.

Forms

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

Rheumatoid Arthritis

Psoriatic Arthritis

Ankylosing Spondylitis:

Crohn’s Disease:

Plaque Psoriasis