Limited Coverage Drugs - Cyclosporine

Generic Name / Strength / Form
cyclosporine / 10 mg, 25 mg, 50 mg, 100 mg / capsule
cyclosporine / 100 mg/mL / solution

Special Authority Criteria	Approval Period
For the treatment of: 1. Diagnosis of rheumatoid arthritis AND prescribed by a rheumatologist. OR 2. Severe ocular inflammatory disease AND prescribed by an ophthalmologist or rheumatologist. OR 3. Extensive psoriasis involving at least 25% of body surface or having psoriasis area and severity index of at least 12 PLUS treatment failure of the following: topical therapy with corticosteroids; and ultraviolet-B light or oral or topical methoxsalen plus ultraviolet-A light AND prescribed by a dermatologist or rheumatologist. OR 4. Psoriasis of the palms and/or soles severe enough to interfere with daily living or work PLUS treatment failure on topical corticosteroids AND prescribed by a dermatologist. OR 5. Nephrotic syndrome AND prescribed by a nephrologist.	Indefinite

Special Authority Criteria

Approval Period

For the treatment of:

1. Diagnosis of rheumatoid arthritis AND prescribed by a rheumatologist.

2. Severe ocular inflammatory disease AND prescribed by an ophthalmologist or rheumatologist.

3. Extensive psoriasis involving at least 25% of body surface or having psoriasis area and severity index of at least 12

PLUS

treatment failure of the following:

AND prescribed by a dermatologist or rheumatologist.

4. Psoriasis of the palms and/or soles severe enough to interfere with daily living or work

PLUS

treatment failure on topical corticosteroids AND prescribed by a dermatologist.

5. Nephrotic syndrome AND prescribed by a nephrologist.

Indefinite

Practitioner Exemptions

Prescriptions for oral cyclosporine written by an exempted prescriber are eligible for PharmaCare coverage without submission of a Special Authority request. No Special Authority record will be created on the PharmaNet system.
For any patient who does not meet the Limited Coverage criteria, a practitioner with an exemption is required to do one of the following:
1. Write on the prescription “Submit as zero cost to PharmaCare”, to indicate to the pharmacist that the prescription is not to be covered by PharmaCare; OR
2. Apply for exceptional PharmaCare coverage by submitting a Special Authority request with full documentation (via fax to 1 800-609-4884). Special Authority requests are subject to review by PharmaCare and will not be covered automatically. If PharmaCare coverage is denied the practitioner must write on the prescription “Submit as zero cost to PharmaCare”.