Limited Coverage Drugs - Rituximab

Generic Name / Strength / Form
rituximab

Criteria Approval Period
1. Treatment of Rheumatoid Arthritis according to established criteria* when prescribed by a rheumatologist Two courses (each course is 1000mg at 0 and 2 weeks, minimum 24 weeks between courses)

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Forms

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