Limited coverage criteria – mycophenolate mofetil

 

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Generic name	mycophenolate mofetil
Strength & form	250 mg capsule 500 mg 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
• Special Authority requests for the treatment of patients 18 years of age and older with active, autoantibody positive moderate to severe systemic lupus erythematosus (SLE), will be considered on a case-by-case basis when coverage is requested by a rheumatologist or dermatologist

Practitioner exemptions

• None

Special Authority request form(s)

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