Limited Coverage Drugs – Tofacitinib for the treatment of Rheumatoid Arthritis

Generic Name

tofacitinib

Strength

5 mg

Form

tablet

Special Authority Criteria

Approval Period

For the treatment of Rheumatoid Arthritis when tofacitinib is prescribed by a rheumatologist according to established criteria, as noted on the relevant Special Authority form below. Tofacitinib is to be used in combination with methotrexate, or without methotrexate in patients who were intolerant to methotrexate.

First approval: 1 year
Renewal: 1 year

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • PharmaCare covers a maximum 30 days’ supply per fill.

Special Authority Request Form(s)

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