Limited Coverage Drugs - Febuxostat

Generic Name                          

febuxostat

Strength

80 mg

Form

tablet

Special Authority Criteria

Approval Period                            

For the reduction of serum uric acid levels in patients with gout who demonstrate immune-mediated hypersensitivity to allopurinol.

Indefinite

Practitioner Exemptions

  • Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:  
    • Pediatric rheumatologists for patients diagnosed with rheumatoid arthritis.

Special Notes

  • Details regarding a patient’s immune-mediated hypersensitivity reaction to allopurinol is required.

Special Authority Request Form(s)