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Limited coverage criteria – adalimumab for non-infectious uveitis

Last updated on March 24, 2025

 

Return to Special Authority drug list

Generic name

adalimumab

Brand name

Strength

Form
Abrilada 20 mg/0.4 mL pre-filled syringe
40 mg/0.8 mL pre-filled syringe
pre-filled pen
Amgevita 20 mg/0.4 mL pre-filled syringe
40 mg/0.8 mL pre-filled syringe
autoinjector
Hadlima 40 mg/0.4 mL autoinjector
pre-filled syringe
40 mg/0.8 mL pre-filled syringe
autoinjector
Hulio 20 mg/0.4 mL pre-filled syringe
40 mg/0.8 mL pre-filled syringe
autoinjector
Hyrimoz 20 mg/0.2 mL pre-filled syringe
40 mg/0.4 mL pre-filled syringe
autoinjector
80 mg/0.8 mL pre-filled syringe
autoinjector
20 mg/0.4 mL pre-filled syringe
40 mg/0.8 mL pre-filled syringe
autoinjector
Idacio 40 mg/0.8 mL pre-filled syringe
pre-filled pen
Simlandi 40 mg/0.4 mL pre-filled syringe
autoinjector
80 mg/0.8 mL pre-filled syringe
Yuflyma 40 mg/0.4 mL pre-filled syringe
pre-filled pen
80 mg/0.8mL pre-filled syringe
pre-filled pen

Special Authority criteria

Approval period

Initial

For the treatment of active1 non-infectious uveitis (NIU) in patients 2 years and older who meet ALL the following criteria:

  • Treatment failure with a minimum 3-month trial of combination therapy consisting of:
    • A corticosteroid (e.g., systemic or opthalmic) and either one of the following:
      • At least one non-biologic immunomodulatory agent for adults, or
      • Methotrexate for pediatric patients 2 to 17 years old

AND

  • Special Authority requests for adalimumab must be submitted by an opthalmologist or rheumatologist with expertise in the treatment of NIU2

1 year

Renewal

  • The patient must attain and maintain a meaningful clinical benefit3 when compared to baseline

AND

  • Special Authority requests for adalimumab must be submitted by an opthalmologist or rheumatologist with expertise in the treatment of NIU2
 1 year

Practitioner exemptions

  • None

Special notes

  • 1Active NIU is defined according to the Standardization of Uveitis Nomenclature (SUN) criteria
  • 2Additional information expected to assist with processing of coverage requests is detailed on the forms linked below (and on the eForms published online)
  • 3Clinical benefit is defined as improvement in at least one of the following parameters:
    • Improved activity in anterior chamber cell grade and/or vitreous haze grade, according to SUN criteria (i.e., two-step decrease in grade or reduction to grade 0)
    • Improved visual acuity (i.e., improvement of 15 letters measured by the ETDRS chart or halving of the visual angle)
    • Reduction in number and/or duration of flares associated with NIU
    • Reduction in number of inflammatory lesions associated with NIU
    • Reduction in corticosteroid use
  • PharmaCare covers a maximum 28-day supply of adalimumab per fill

Special Authority request form(s)