Limited Coverage Drugs – Certolizumab for the treatment of Ankylosing Spondylitis

Generic Name

certolizumab

Strength

200 mg/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 certolizumab for the treatment of Ankylosing Spondylitis is available only when certolizumab is prescribed by a rheumatologist

1 year

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)

Click on the appropriate Special Authority Form below for full criteria.