Limited coverage criteria – certolizumab for ankylosing spondylitis

Last updated on March 17, 2025

Generic name	certolizumab
Strength & form	200 mg/mL 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 a Special Authority request is submitted by a rheumatologist	1 year

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 a Special Authority request is submitted by a rheumatologist

1 year

Practitioner exemptions

None

Special notes

None

Special Authority request form(s)

Click on the appropriate Special Authority request form below for full criteria.

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