Limited coverage drugs – donepezil

Generic name



5 mg, 10 mg



Special Authority criteria

Approval period

For the treatment of mild to moderate Alzheimer’s disease, Alzheimer’s disease with a vascular component, Alzheimer’s disease with Parkinsonian features (Lewy bodies), or mixed dementia with Alzheimer’s disease, in patients with:


Initial: 6 months

Renewal: 1 year

Practitioner exemptions

  • None

Special notes

  • Coverage is not available for patients switching from one cholinesterase inhibitor to another due to ineffectiveness (clinical failure), because there is insufficient evidence that switching to a different cholinesterase inhibitor will provide a better therapeutic effect
  • Patients must be assessed on a regular basis (every 6 months) to ensure continued therapeutic benefit

Special Authority request form(s)