Limited Coverage Drugs - adalimumab

BIOSIMILAR TRANSITION INITIATIVE

PharmaCare is changing coverage of adalimumab products for conditions which include:

  • rheumatoid arthritis (RA)
  • ankylosing spondylitis (AS)
  • psoriatic arthritis (PsA)
  • plaque psoriasis (PsO) for adults
  • hidradenitis suppurativa (HS) for adults
  • polyarticular juvenile idiopathic arthritis (pJIA)
  • Crohn’s disease (CD)
  • ulcerative colitis (UC)

To maintain PharmaCare coverage, patients currently covered for Humira® must, in consultation with their prescriber, switch to an approved biosimilar product: Amgevita™, Hadlima®, Hulio®, Hyrimoz® or Idacio®.

April 7, 2021 - All new Special Authority (SA) requests including renewals for adalimumab will only be approved for Amgevita, Hadlima*, Hulio, Hyrimoz or Idacio.
*At this time, Hadlima is not indicated for pediatric Crohn’s disease.

April 7, 2021 to October 6, 2021 – During the six-month transition period, patients with PharmaCare coverage for Humira and who wish to maintain their coverage must transition to an approved biosimilar product. All five biosimilar brands will be covered for patients with existing adalimumab SAs, with no new request required for coverage of the biosimilar until the SA’s next renewal date. To maintain patients’ coverage, prescribers must write a new prescription for their patients on Humira, indicating the transition to a specific biosimilar.

October 7, 2021 - Coverage for Humira comes to an end and only the approved biosimilar products are authorized for continued coverage.

Special Authority requests for patients who are unable to transition to biosimilars will be considered on an exceptional case-by-case basis.

Generic Name

adalimumab

Brand Name

Dosage Form

Strength

Amgevita

pre-filled syringe (PFS)
PFS
autoinjector

20 mg/0.4 mL
40 mg/0.8 mL
40 mg/0.8 mL

Hadlima

PFS
autoinjector

40 mg/0.8 mL
40 mg/0.8 mL

Hulio

PFS
pre-filled pen (PEN)

40 mg/0.8 mL
40 mg/0.8 mL

Hyrimoz

PFS
PFS
autoinjector

20 mg/0.4 mL
40 mg/0.8 mL
40 mg/0.8 mL

Idacio

PEN
PFS

40 mg/0.8 mL
40 mg/0.8 mL

Special Authority Criteria

Approval Period

1. Treatment of rheumatoid arthritis according to established criteria* when prescribed by a rheumatologist.

  • First approval: 1 year
  • Renewal: 1 year to indefinite

2. Treatment of ankylosing spondylitis according to established criteria* when prescribed by a rheumatologist.

  • First approval: 1 year
  • Renewal: 1 year to indefinite

3. Treatment of psoriatic arthritis according to established criteria* when prescribed by a rheumatologist.

  • First approval: 1 year
  • Renewal: 1 year to indefinite

4. Treatment of moderate to severe plaque psoriasis, according to established criteria* when prescribed by a dermatologist.

  • First approval: 16 weeks
  • Renewal: 1 year

5. Treatment of moderate to severe active polyarticular juvenile idiopathic arthritis for patients 2 years and older, who, due to intolerance or lack of efficacy, have not adequately responded to methotrexate.

Approval: 1 year

6. For the treatment of adult patients with active moderate to severe hidradenitis suppurativa according to established criteria* prescribed by a dermatologist.

  • First approval: 6 months
  • Renewal: 1 year

7. For the treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease, according to established criteria* when prescribed by a gastroenterologist.

Note: Hadlima is currently not indicated for pediatric CD.

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

8. For the treatment of moderate to severe ulcerative colitis, according to criteria* prescribed by a gastroenterologist.

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

Practitioner Exemptions

  • Pediatric rheumatologists for pediatric patients diagnosed with polyarticular juvenile idiopathic arthritis (pJIA)

Special Notes

  • PharmaCare covers a maximum 28-day supply of adalimumab per fill.

Special Authority Request Form(s)

Biosimilars Initiative Support

*Click on the appropriate Special Authority form below for full criteria:

Rheumatoid arthritis

Ankylosing spondylitis

Crohn’s disease

Hidradenitis suppurativa

Psoriatic arthritis

Plaque psoriasis

Ulcerative colitis