Limited Coverage Drugs - Adalimumab for the treatment of Ankylosing Spondylitis

Generic Name

adalimumab

Strength

40 mg / 0.8 mL

Form subcutaneous injection solution

Special Authority Criteria

Approval Period

For the treatment of Ankylosing Spondylitis according to established criteria described in the Special Authority Request forms 5365 (Initial/Switch) and 5366 (Renewal), below.

Coverage of adalimumab for the treatment of Ankylosing Spondylitis is only available when adalimumab is prescribed by a rheumatologist.

First approval: 1 year
Renewal: 1 year to indefinite

Practitioner Exemptions

  • None

Special Notes

  • The maximum covered allowable supply of adalimumab is 28 days per fill.

Special Authority Request Form(s)