Limited Coverage Drugs - Adalimumab

Generic Name / Strength / Form
adalimumab

Criteria

Approval Period

1. Treatment of Rheumatoid Arthritis according to established criteria* as prescribed by a rheumatologist

First approval: 1 year
Renewal: 1 year to indefinite

2. Treatment of Psoriatic Arthritis according to established criteria* as prescribed by a rheumatologist

First approval: 1 year
Renewal: 1 year to indefinite

3. Treatment of Ankylosing Spondylitis according to established criteria* as prescribed by a rheumatologist

First approval: 26 weeks
Renewal: 1 year to indefinite

4. Treatment of moderate to severe active Crohn's disease or fistulizing Crohn’s disease according to established criteria* as prescribed by a gastroenterologist.

First approval (induction period): 12 weeks
Renewal: 1 year

Practitioner Exemptions

  • None

Special Notes

  • Ankylosing spondylitis coverage became effective March 14, 2008.Coverage for infliximab for psoriatic arthritis became effective March 14, 2008. Coverage for adalimumab for moderate to severe active Crohn’s disease and fistulizing Crohn’s disease became effective September 9, 2008.
  • For coverage, the maximum allowable supply of adalimumab is for 28 days per fill.

Special Authority Request Forms

* Click on the appropriate Special Authority Form below for full criteria: