Limited Coverage Drugs - Adalimumab for the treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease

Generic Name

adalimumab
Strength 40 mg / 0.8 mL

Form

subcutaneous injection solution

Special Authority Criteria

Approval Period

For the treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease according to established criteria requirements described in Special Authority Request form 5368, below.

Coverage of adalimumab for the treatment of Crohn's disease or fistulizing Crohn's disease is only available when adalimumab is prescribed by a gastroenterologist.

First approval (induction period):
12 weeks
Renewal: 1 year

Practitioner Exemptions

  • None

Special Notes

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

Special Authority Request Form(s)