Limited coverage criteria – donepezil

Last updated on March 4, 2025

Special Authority requests can now be submitted online. It's simple and quick!

This drug is eligible for automatic approval when patient meets criteria and the request is submitted through eForms

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

Special Authority criteria	Approval period
For the treatment of mild to moderate Alzheimer’s disease, Alzheimer’s disease with a vascular component, Alzheimer’s disease with Parkinsonian features (Lewy bodies), or mixed dementia with Alzheimer’s disease, in patients with: A Standardized Mini Mental State Examination (SMMSE) (PDF, 690KB) score of ≥ 10 to ≤ 26 AND A Global Deterioration Scale (GDS) (PDF,198KB) stage of ≥ 4 to ≤ 6	Initial: 6 months Renewal: 1 year for first renewal, and indefinite coverage on second renewal.

Special Authority criteria

Approval period

For the treatment of mild to moderate Alzheimer’s disease, Alzheimer’s disease with a vascular component, Alzheimer’s disease with Parkinsonian features (Lewy bodies), or mixed dementia with Alzheimer’s disease, in patients with:

A Standardized Mini Mental State Examination (SMMSE) (PDF, 690KB) score of ≥ 10 to ≤ 26

AND

A Global Deterioration Scale (GDS) (PDF,198KB) stage of ≥ 4 to ≤ 6

Initial: 6 months

Renewal: 1 year for first renewal, and indefinite coverage on second renewal.

Practitioner exemptions

None

Special notes

Coverage is not available for patients switching from one cholinesterase inhibitor to another due to ineffectiveness (clinical failure), because there is insufficient evidence that switching to a different cholinesterase inhibitor will provide a better therapeutic effect
Patients must be assessed on a regular basis (every 6 months) to ensure continued therapeutic benefit
Criteria applicable to all plans including Plan G

Special Authority request form

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