Limited Coverage Drugs - Etanercept

Limited Coverage Drugs – Etanercept

Generic Name

etanercept

Strength

25 mg, 50 mg

Form

Brenzys®: 50 mg/mL solution for injection in a pre-filled syringe or pre-filled auto-injector.

Enbrel®: 25 mg/vial powder for reconstitution, 50 mg/mL solution for injection in a pre-filled syringe or auto-injector.

Erelzi™: 25 mg/0.5 mL solution for injection in a pre-filled syringe, 50 mg/mL solution for injection in a pre-filled syring or auto-injector.

 

 Special Authority Criteria

 

 Approval Period                                                 

 Brand Coverage

 

  1. For the treatment of rheumatoid arthritis according to criteria detailed in HLTH 5345 (initial/switch) or HLTH 5354 (renewal) and when prescribed by a rheumatologist.

 First approval: 1 year
 Renewal: 1 year to indefinite

  • New starts: Brenzys or Erelzi
  • Erelzi: for patients granted SA as of November 14, 2017.
  • Brenzys: for patients granted SA as of July 18, 2017.
  • Enbrel: only for patients granted SA prior to July 18, 2017.
  1. For the treatment of ankylosing spondylitis according to criteria detailed in HLTH 5365 (initial/switch) or HLTH 5366 (renewal) and when prescribed by a rheumatologist.

 First approval: 1 year
 Renewal: 1 year to indefinite

  • New starts: Brenzys or Erelzi
  • Erelzi: for patients granted SA as of November 14, 2017.
  • Brenzys: for patients granted SA as of July 18, 2017.
  • Enbrel: only for patients granted SA prior to July 18, 2017.
  1.  For the treatment of psoriatic arthritis according to criteria detailed in HLTH 5360 (initial/switch) or HLTH 5361 (renewal) and when prescribed by a rheumatologist.
 First approval: 1 year
 Renewal: 1 year to indefinite
  • New starts: Erelzi
  • Erelzi: for patients granted SA as of April 9, 2019.
  • Enbrel: only for patients granted SA prior to April 9, 2019.
  1. For the treatment of moderate to severe psoriasis, according to criteria detailed in HLTH 5380 (initial/switch/renewal) and when prescribed by a dermatologist.
 First approval: 12 weeks
 Renewal: 1 year
  • Enbrel only

 

Practitioner Exemptions

  • Pediatric rheumatologists do not have to complete an SA request for pediatric patients diagnosed with common pediatric rheumatology indications when using up to 50 mg of etanercept weekly.

Special Notes

  • PharmaCare covers a maximum 28-day supply of etanercept per fill.

Special Authority Request Forms

Rheumatoid Arthritis

Ankylosing Spondylitis

Psoriatic Arthritis

Plaque Psoriasis