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.