Limited Coverage Drugs - Adalimumab for the treatment of moderate to severe Psoriasis

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 psoriasis according to established criteria requirements described in Special Authority Request form 5380, below.

Coverage of adalimumab for the treatment of moderate to severe psoriasis is available only when adalimumab is prescribed by a dermatologist.

First approval: 16 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)