Limited Coverage Drugs – Certolizumab

Generic Name

certolizumab

Strength

200 mg/mL
Form subcutaneous injection solution

Special Authority Criteria

Approval Period

Ankylosing Spondylitis

For the treatment of Ankylosing Spondylitis when:

  • prescribed by a rheumatologist 

AND 

  • prescribed according to established criteria (as indicated on the relevant Special Authority form below).

First approval: 1 year

Renewal: 1 year or indefinite

Psoriatic Arthritis

For the treatment of Psoriatic Arthritis when:

  • prescribed by a rheumatologist 

AND 

  • prescribed according to established criteria (as indicated on the relevant Special Authority form below).

First approval: 1 year

Renewal: 1 year or indefinite

Rheumatoid Arthritis

For the treatment of Rheumatoid Arthritis when:

  • prescribed by a rheumatologist 

AND 

  • prescribed according to established criteria (as indicated on the relevant Special Authority form below). 

First approval: 1 year

Renewal: 1 year or indefinite

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)

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