Limited Coverage Drugs - Special Authority Criteria

Generic Name

methotrexate sodium
Strength Vials: 10 mg/mL and 25 mg/mL or
Pre-filled syringes: 7.5 mg/0.3mL, 10 mg/0.4 mL , 15 mg/0.6 mL, 20 mg/0.8 mL, 25 mg/mL
Form sterile solution

Criteria

Approval Period

VIALS

For the treatment of rheumatoid arthritis, when the patient demonstrates failure on or intolerance to oral methotrexate.

Indefinite

PRE-FILLED SYRINGES

For the treatment of rheumatoid arthritis, when the patient demonstrates failure on or intolerance to oral methotrexate, and they are unable to handle or use vials.

Indefinite

Practitioner Exemptions

  • Rheumatologists are exempt from submitting SA requests to secure coverage of vials of methotrexate injection solution for their patients (pre-filled syringes require SA).

Special Notes

  • Oral methotrexate is a regular benefit under Plan I (Fair PharmaCare) and Plans B (Permanent Residents of Licensed Residential Care Facilities), C (Income Assistance), F (Children in the At-Home Program), and W (First Nations Health Benefits).
  • Methotrexate sodium vials (not pre-filled syringes) are a regular benefit for Permanent Residents of Licensed Residential Care Facilities (Plan B). 

Special Authority Request Form(s)