Limited Coverage Drugs – tofacitinib for the treatment of ulcerative colitis

Generic Name

tofacitinib

Strength

5 mg, 10 mg

Form

tablet

Special Authority Criteria

Approval Period

For the treatment of moderate to severe ulcerative colitis (UC), according to criteria detailed in HLTH 5388 (Initial/Switch) (PDF, 657KB) or HLTH 5497 (Renewal) (PDF, 653KB), and when prescribed by a gastroenterologist.

Initial: 8 weeks

Renewal: one year

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Can not be used in combination with biologic drugs for UC

Special Authority Request Form(s)