Limited Coverage Drug – Special Authority Criteria

Generic Name / Strength / Form

leflunomide

Criteria

Approval Period

Diagnosis of rheumatoid arthritis and prescribed by a rheumatologist
PLUS
failure or intolerance to at least two of the following, including methotrexate: gold, anti-malarials, methotrexate, sulfasalazine, azathioprine, penicillamine, chlorambucil, cyclophosphamide or cyclosporine.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)

General Special Authority Request Form (PDF, 524KB)
Click on the link to complete a special authority request form.