Limited coverage criteria – methotrexate pre-filled syringes

Last updated on March 19, 2025

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Generic name	methotrexate sodium
Strength & form	7.5 mg/0.3mL/10 mg/0.4 mL/15 mg/0.6 mL/20 mg/0.8 mL/25 mg/mL pre-filled syringe

Special Authority criteria	Approval period
For the treatment of rheumatoid arthritis when the patient demonstrates failure on or intolerance to oral methotrexate AND they are unable to handle or use vials	Indefinite

Practitioner exemptions

None

Special notes

Oral methotrexate sodium and methotrexate sodium vials are regular benefits under Fair PharmaCare, Plan B, Plan C, Plan F and Plan W

Special Authority request form(s)

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HLTH 5328 – General Special Authority request (PDF, 656KB)

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Limited coverage criteria – methotrexate pre-filled syringes

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)