Limited Coverage Drugs - Adalimumab

Generic Name / Strength / Form
adalimumab

Criteria

Approval Period

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

First approval: 1 year
Renewal: 1 year to indefinite

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

First approval: 1 year
Renewal: 1 year to indefinite

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

First approval: 1 year
Renewal: 1 year to indefinite

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

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

5. Treatment of moderate to severe psoriasis, according to established criteria* when prescribed by a dermatologist

First approval: 16 weeks
Renewal: 1 year

Practitioner Exemptions

  • None

Special Notes

  • For coverage, the maximum allowable supply of adalimumab is 28 days per fill.

Special Authority Request Forms

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

Rheumatoid Arthritis

Psoriatic Arthritis

Ankylosing Spondylitis:

Crohn’s Disease:

Plaque Psoriasis