Limited Coverage Drugs - Infliximab

Generic Name

infliximab

Strength

100 mg

Form

Vial for Infusion

Inflectra™ (new patients)

Remicade® (patients granted Special Authority prior to Feb. 19, 2016)

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

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

First approval: 1 year
Renewal: 1 year to indefinite

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

First approval: 1 year
Renewal: 1 year to indefinite

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

First approval (induction period): 3 doses
Renewal: 1 year

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

Inflectra™ (new patients)

Remicade® (patients granted Special Authority prior to Nov. 1, 2016)

  1. Treatment of  moderate to severe active Crohn's disease or fistulising Crohn’s disease according to established criteria* when prescribed by a gastroenterologist.
First approval (induction period): 3 doses (Inflectra™ only)
Renewal: 1 year (Inflectra™ and Remicade®)

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

Inflectra™ only

  1. Treatment of moderate to severe Ulcerative Colitis according to established criteria* when prescribed by a gastroenterologist.
First approval (induction period): 3 doses
Renewal: 1 year

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

Practitioner Exemptions

  • Pediatric gastroenterologists and pediatric rheumatologists have exemption for both Inflectra and Remicade.

Special Notes

  • PharmaCare covers only the Inflectra brand for patients using infliximab for the first time for the indications above.
  • For the rheumatoid and psoriasis indications above, PharmaCare covers Remicade and Inflectra for patients who were granted a Special Authority for Remicade before Feb. 19, 2016.
  • For Crohn’s disease, PharmaCare covers Remicade and Inflectra for patients who were granted a Special Authority for Remicade before Nov. 1, 2016.
  • PharmaCare does not cover Remicade for the treatment of ulcerative colitis.
  • PharmaCare covers a maximum of 56 days per fill for infliximab. One infusion (dose) usually provides treatment for 56 days or less.

Special Authority Request Form(s)

Rheumatoid Arthritis:

Psoriatic Arthritis:

Ankylosing Spondylitis:

Plaque Psoriasis:

Crohn’s Disease:

Ulcerative Colitis (Inflectra brand only):