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: 12 weeks 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)
- HLTH 5379 - Psoriasis Area and Severity Index (PASI) Worksheet (PDF)
- HLTH 5380 - Biologics for Moderate to Severe Psoriasis (PDF)
- HLTH 5360: Targeted DMARDs for Psoriatic Arthritis—Initial/Switch (PDF)
- HLTH 5361: Targeted DMARDs for Psoriatic Arthritis—Renewal (PDF)
- HLTH 5364: Bath Ankylosing Spondylitis Disease Activity Index BASDAI (PDF)
- HLTH 5383: Health Assessment Questionnaire (PDF)