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: A Standardized Mini Mental State Examination (SMMSE) (PDF, 690KB) score of ≥ 10 to ≤ 26 AND A Global Deterioration Scale (GDS) (PDF,198KB) stage of ≥ 4 to ≤ 6	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
• Criteria applicable to all plans including Plan G

  Special Authority request form(s)

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  • 5465 - Donepezil, Galantamine and Rivastigmine (PDF, 350KB)