Limited coverage criteria – tofacitinib (for rheumatoid arthritis)
Last updated on March 24, 2025
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Generic name |
tofacitinib |
|---|---|
Strength & form |
5 mg, 11 mg tablet and extended-release tablet |
Special Authority criteria |
Approval period |
|---|---|
|
For the treatment of rheumatoid arthritis when a Special Authority request for tofacitinib is submitted by a rheumatologist according to established criteria, as noted in eForms submission (and on the Special Authority forms linked below) Tofacitinib is to be used in combination with methotrexate, or without methotrexate in patients who are intolerant to methotrexate |
Initial: 1 year Renewal: 1 year or indefinite |
Practitioner exemptions
- None
Special notes
- PharmaCare covers a maximum 30 days' supply per fill
- PharmaCare coverage is limited to 5 mg of tofacitinib twice daily, or one 11 mg tablet once daily
Special Authority request form(s)
- Log in to eForms
- HLTH 5345: Targeted DMARDs for Rheumatoid Arthritis: Initial/Switch (PDF, 453KB)
- HLTH 5354: Targeted DMARDs for Rheumatoid Arthritis: Renewal (PDF, 399KB)
- HLTH 5383: Health Assessment Questionnaire (PDF, 528KB) - patient completes; to accompany both forms above