Limited Coverage Drugs - Infliximab

Generic Name

infliximab

Strength

100 mg/vial

Form

Powder for solution

Inflectra™ (new patients) and Renflexis™ (new patients as of August 21, 2018)

Remicade® (patients granted Special Authority prior to February 19, 2016)

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

  1. Treatment of Psoriatic Arthritis according to established criteria when prescribed by a rheumatologist.

First approval: 1 year
Renewal: 1 year to indefinite

  1. Treatment of Ankylosing Spondylitis according to established criteria when prescribed by a rheumatologist.

First approval: 1 year
Renewal: 1 year to indefinite

  1. Treatment of moderate to severe Psoriasis, according to established criteria, when prescribed by a dermatologist.

First approval (induction period): 3 doses
Renewal: 1 year

Inflectra™ (new patients) and Renflexis™ (new patients as of August 21, 2018)

Remicade® (patients granted Special Authority prior to November 1, 2016)

Special Authority Criteria Approval Period
  1. Treatment of  moderate to severe active Crohn's disease or fistulising Crohn’s disease according to established criteria when prescribed by a gastroenterologist.

First approval (induction period): 3 doses

Renewal: 1 year 

Inflectra™ and Renflexis™ 

Special Authority Criteria Approval Period
  1. Treatment of moderate to severe Ulcerative Colitis according to established criteria when prescribed by a gastroenterologist.

First approval (induction period): 3 doses

Renewal: 1 year

 

Practitioner Exemptions

  • Pediatric rheumatologists have an exemption for Inflectra , Renflexis and Remicade.

Special Notes

  • PharmaCare covers only the Inflectra and Renflexis brands for patients using infliximab for the indications above.
  • For the rheumatoid and psoriasis indications above, PharmaCare covers Remicade, Inflectra and Renflexis for patients who were granted a Special Authority for Remicade before Feb. 19, 2016.
  • For Crohn’s disease, PharmaCare covers Remicade, Inflectra and Renflexis for patients who were granted a Special Authority for Remicade before Nov. 1, 2016.
  • PharmaCare does not cover Remicade for the treatment of ulcerative colitis.
  • PharmaCare covers a maximum of 56 days per fill for infliximab. One infusion (dose) usually provides treatment for 56 days or less.

Special Authority Request Form(s)

Rheumatoid Arthritis:

Psoriatic Arthritis:

Ankylosing Spondylitis:

Plaque Psoriasis:

Crohn’s Disease:

Ulcerative Colitis: