Limited coverage criteria – tofacitinib (for ulcerative colitis)

Last updated on March 24, 2025

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Generic name	tofacitinib
Strength & form	5 mg, 10 mg tablet

Special Authority criteria	Approval period
For the treatment of moderate to severe ulcerative colitis (UC), according to criteria detailed in HLTH 5388 (Initial/Switch) (PDF, 657KB) or HLTH 5497 (Renewal) (PDF, 653KB), AND When a Special Authority request is submitted by a gastroenterologist	Initial: 8 weeks Renewal: 1 year

Special Authority criteria

Approval period

For the treatment of moderate to severe ulcerative colitis (UC), according to criteria detailed in HLTH 5388 (Initial/Switch) (PDF, 657KB) or HLTH 5497 (Renewal) (PDF, 653KB),

AND

When a Special Authority request is submitted by a gastroenterologist

Initial: 8 weeks

Renewal: 1 year

Practitioner exemptions

None

Special notes

PharmaCare covers a maximum 30 days' supply per fill
Coverage is limited to 10 mg twice daily dosing for 8 weeks (loading doses) then 5 mg twice daily dosing thereafter
Cannot be used in combination with biologic drugs for ulcerative colitis

Special Authority request form(s)

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