Limited coverage criteria – sarilumab

Last updated on March 21, 2025

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Generic name	sarilumab
Strength & form	150 mg/1.14 mL, 200 mg/ 1.14 mL pre-filled syringe or pre-filled pen for subcutaneous injection

Special Authority criteria	Approval period
For the treatment of rheumatoid arthritis (RA) when: Special Authority request is submitted by a rheumatologist AND According to established criteria (as indicated on the applicable Special Authority form below)	Initial: 1 year Renewal: 1 year

Special Authority criteria

Approval period

For the treatment of rheumatoid arthritis (RA) when:

Special Authority request is submitted by a rheumatologist

AND

According to established criteria (as indicated on the applicable Special Authority form below)

Initial: 1 year

Renewal: 1 year

Practitioner exemptions

None

Special notes

PharmaCare covers a maximum 28-day supply of sarilumab per fill. Coverage is limited to 200 mg or 150 mg every 2 weeks

Special Authority request form(s)

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