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

solution for subcutaneous injection

Special Authority Criteria

Approval Period

For the treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease, according to criteria detailed in HLTH 5368 (Initial/Switch) or HLTH 5495 (Renewal), and when 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 Forms