Limited Coverage Drugs - Etanercept

Limited Coverage Drugs – Etanercept

Generic Name

etanercept

Strength

25 mg, 50 mg

Form

Brenzys™â€•50 mg solution for injection in a pre-filled syringe or pre-filled auto-injector

Enbrel®â€•25 mg powder for reconstitution in a vial, 50 mg solution for injection in a pre-filled syringe or pre-filled auto-injector

Erelzi™â€•25 mg and 50 mg solution for injection in a pre-filled syringe, 50 mg pre-filled auto-injector

 

Brenzys™ (new patients as of July 18, 2017) and
Erelzi™ (new patients as of November 14, 2017)

 

Enbrel® (patients granted Special Authority prior to July 18, 2017)

Special Authority Criteria

Approval Period

1. Treatment of rheumatoid arthritis according to established criteria* when prescribed by a rheumatologist.

First approval: 1 year
Renewal: 1 year to indefinite

2. Treatment of ankylosing spondylitis according to established criteria* when prescribed by a rheumatologist.

First approval: 1 year
Renewal: 1 year to indefinite

 

Enbrel® only

Special Authority Criteria

Approval Period

3. Treatment of psoriatic arthritis according to established criteria* when prescribed by a rheumatologist.

First approval: 1 year
Renewal: 1 year to indefinite

4. Treatment of moderate to severe psoriasis, according to established criteria* when prescribed by a dermatologist.

First approval: 12 weeks
Renewal: 1 year

Practitioner Exemptions

  • Pediatric rheumatologists for pediatric patients diagnosed with rheumatoid arthritis.

Special Notes

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

Special Authority Request Form(s)

* Click on the appropriate Special Authority Form below for full criteria:

Rheumatoid Arthritis

Ankylosing Spondylitis

Psoriatic Arthritis

Plaque Psoriasis