Limited coverage criteria – mycophenolate mofetil

 

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Generic name	mycophenolate mofetil
Strength & form	250 mg/500 mg 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

• ¹An inadequate response is defined as some or no improvement in laboratory or histologic features despite compliance
• ²An inadequate response is defined as a ≤50% reduction in new occurrence or severity of blisters and lesions from pre-treatment baseline
• ³Details of benefits seen while on mycophenolate mofetil and rationale for ongoing treatment is required
• Special Authority requests for the treatment of moderate to severe atopic dermatitis will be considered on a case-by-case basis when coverage is requested by a dermatologist, allergist, or clinical immunologist

Practitioner exemptions

• None

Special Authority request form(s)

• Log in to eForms
• HLTH 5328 – General Special Authority request (PDF, 656KB)