Limited coverage drugs – mycophenolate mofetil

Generic name	mycophenolate mofetil
Strength	250 mg, 500 mg
Form	capsule, tablet

Special Authority criteria	Approval period
For the treatment of autoimmune hepatitis when the patient has had an inadequate response1 to combination therapy of azathioprine and a corticosteroid at maximally-tolerated doses.	Initial: 1 year Renewal: Indefinite3
For the treatment of bullous pemphigoid when the patient has had an inadequate response2 to combination therapy of the following at maximally-tolerated doses: methotrexate or azathioprine AND a corticosteroid	Initial: 1 year Renewal: Indefinite3

Special notes

1. An inadequate response is defined as some or no improvement in laboratory or histologic features despite compliance
2. An inadequate response is defined as a ≤50% reduction in new occurrence or severity of blisters and lesions from pre-treatment baseline
3. Details of benefits seen while on mycophenolate mofetil and rationale for ongoing treatment is required
4. Special authority requests for the treatment of moderate to severe atopic dermatitis will be considered on a case-by-case basis when coverage is requested by a dermatologist, allergist, or clinical immunologist

Practitioner exemptions

• No practitioner exemptions

Special Authority request form(s)

• Log in to eForms
• 5328 - General Special Authority Request