Limited Coverage Drugs - Teriflunomide
Generic Name |
teriflunomide |
Strength |
14 mg |
Form | film-coated tablet |
Special Authority Criteria |
Approval Period |
Initial: As first-line monotherapy for the treatment of relapsing-remitting multiple sclerosis (MS) diagnosed according to the current McDonaldi clinical criteria and magnetic resonance imaging (MRI) evidence, when prescribed by a neurologist from a designated MS clinic, for patients who meet ALL of the following criteria:
Note:
Renewal: As monotherapy, when prescribed by a neurologist from a designated MS clinic, for the treatment of patients with relapsing-remitting MS, AND who have demonstrated that the therapeutic benefits outweigh any potential risks, as shown by relapse rate, EDSS, MRI scan, or overall clinical impression. Change of Therapy: As monotherapy, when prescribed by a neurologist from a designated MS clinic, for the treatment of patients with relapsing-remitting MS who have experienced failure or intolerance to a previous disease modifying therapy |
1 year
1 year
1 year |
Practitioner Exemptions
- A Collaborative Prescribing Agreement (CPA) is available to neurologists specializing in MS whose primary place of practice is in a designated MS clinic. Neurologists who have signed a CPA are not required to submit a Special Authority request form for coverage.
- Important: PharmaCare coverage covers teriflunomide for patients who meet the Limited Coverage criteria and whose prescription has been written by a neurologist who has entered into a CPA.
- PharmaCare coverage and actual reimbursement is subject to the rules of a patient's PharmaCare plan, including any annual deductible requirement and any other applicable PharmaCare pricing policy.
- Each CPA must be signed by the neurologist who is requesting coverage and not a delegate.
- Practitioners who have not signed a CPA may submit a Special Authority request if the patient meets the criteria above. These prescriptions will not be covered automatically.
Special Notes
- None