Limited Coverage Drugs – Certolizumab for the treatment of Ankylosing Spondylitis

Last updated on August 7, 2024

Generic Name

certolizumab

Strength

200 mg/mL
Form subcutaneous injection solution

Special Authority Criteria

Approval Period

For the treatment of ankylosing spondylitis according to established criteria described in the Special Authority forms 5365 (Initial/Switch) and 5366 (Renewal), below.

Coverage of certolizumab for the treatment of ankylosing spondylitis is available only when certolizumab is prescribed by a rheumatologist

1 year

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)

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