Limited Coverage Drugs – Adalimumab for the treatment of Hidradentis Suppurativa (HS)

Generic Name:

adalimumab

Strength:

40 mg / 0.8 mL

Form:

subcutaneous injection solution

Special Authority Criteria

Approval Period

For the treatment of adult patients with active moderate to severe hidradenitis suppurativa (HS) according to established criteria requirements described in Special Authority Request form 5485, below.

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

First approval: 6 months

Renewal: 1 year

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • PharmaCare covers a maximum of 28 days per fill for adalimumab.
  • See form for more details.

Special Authority Request Form(s)