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.

Practitioner Exemptions

  • No practitioner exemptions.

Special Authority Request Form(s)