Limited Coverage Drugs - Etanercept

  Generic Name

  etanercept

  Strength

  25mg, 50 mg

  Form

  Brenzys™: 50 mg solution for injection in a pre-filled syringe or pre-filled auto-injector

  Enbrel®: 25mg powder for reconstitution in a vial,

  50 mg solution for injection in a pre-filled syringe or pre-filled auto-injector

Brenzys™ (new patients)

Enbrel® (patients granted Special Authority prior to July 18, 2017)

  Special Authority 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 Ankylosing Spondylitis according to established criteria* when
      prescribed by a rheumatologist.

  First approval: 1 year
  Renewal: 1 year to indefinite

Enbrel® only

  Special Authority Criteria

  Approval Period

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

  First approval: 1 year
  Renewal: 1 year to indefinite

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

  First approval: 12 weeks
  Renewal: 1 year

Practitioner Exemptions

  • Pediatric rheumatologists for pediatric patients diagnosed with rheumatoid arthritis.

Special Notes

  • PharmaCare covers a maximum 28-day supply of etanercept per fill.

Special Authority Request Form(s)

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

Rheumatoid Arthritis

Ankylosing Spondylitis:

Psoriatic Arthritis

Plaque Psoriasis