Limited Coverage Drugs - Vedolizumab

Generic Name

vedolizumab                                                                 

Strength

300 mg/vial

Form

Solution for Infusion

Special Authority Criteria

Approval Period
  1. For the treatment of moderate to severe active Crohn's disease, according to criteria detailed in HLTH 5368 (Initial/Switch) or HLTH 5495 (Renewal), and when prescribed by a gastroenterologist.

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

  1. For the treatment of moderate to severe Ulcerative Colitis, according to criteria detailed in HLTH 5388 (initial/Switch) or HLTH 5497 (Renewal), and when prescribed by a gastroenterologist.

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

Practitioner Exemptions

  • None

Special Notes

  • PharmaCare covers a maximum of 56 days per fill for vedolizumab.

Special Authority Request Forms

Crohn's Disease

Ulcerative Colitis