Limited Coverage Drugs - Donepezil

Generic Name

Donepezil                                                                                                                                               
Strength 5 mg, 10 mg

Form

tablet

Special Authority Criteria

Approval Period

For the treatment of mild to moderate  Alzheimer’s disease, Alzheimer’s disease with a vascular component, Alzheimer’s disease with Parkinsonian features (Lewy bodies), or mixed dementia with Alzheimer’s disease, in patients with:

AND

Initial: 6 months

Renewal: 1 year

Practitioner Exemptions

  • None

Special Notes

  • Coverage is not available for patients switching from one cholinesterase inhibitor to another due to ineffectiveness 
    (clinical failure), because there is insufficient evidence that switching to a different cholinesterase inhibitor will provide a better therapeutic effect.
  • Patients must be assessed on a regular basis (every 6 months) to ensure continued therapeutic benefit.

Special Authority Request Form(s)