Limited Coverage Drugs - Adalimumab for the treatment of Ulcerative Colitis

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 Ulcerative Colitis, according to criteria detailed in HLTH 5388 (Initial/Switch) or HLTH 5497 (Renewal), and when prescribed by a gastroenterologist.

First approval (induction period): 12 weeks

Renewal: 1 year


 

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • PharmaCare covers a maximum of 28 days per fill for adalimumab.

Special Authority Request Form(s)