Limited Coverage Drug – Special Authority Criteria

Generic Name

leflunomide

Strength

10 mg, 20 mg

Form

tablet

 

Criteria

Approval Period

For the treatment of rheumatoid arthritis when:

  • prescribed by a rheumatologist

AND

  • the patient demonstrates failure on or intolerance to at least two of the following: gold, anti-malarials, methotrexate, sulfasalazine, azathioprine, penicillamine, chlorambucil, cyclophosphamide or cyclosporine..

Indefinite

Practitioner Exemptions

  • Rheumatologists

Special Notes

  • None

Special Authority Request Form(s)

General Special Authority Request Form (PDF, 524KB)