Limited Coverage Drugs – Ixekizumab

Generic Name:

ixekizumab

Strength:

80 mg/1 mL

Form:

solution for subcutaneous injection in a pre-filled syringe or pre-filled auto-injector

Special Authority Criteria

Approval Period

For the treatment of moderate to severe Plaque Psoriasis, according to criteria detailed in HLTH 5380, when prescribed by a dermatologist.

First approval: 12 weeks

Renewal: 1 year

For the treatment of moderate to severe Psoriatic Arthritis, according to criteria detailed in HLTH 5360 (Initial/Switch) or HLTH 5361 (renewal), and when prescribed by a rheumatologist.

First approval: 1 year

Renewal: 1 year

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

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

Special Authority Request Form(s)