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 Annual renewal: 1 year
2. Treatment of Psoriatic Arthritis according to established criteria* as prescribed by a rheumatologist	First approval: 1 year Annual renewal: 1 year
3. Treatment of Ankylosing Spondylitis according to established criteria* as prescribed by a rheumatologist	First approval: 26 weeks Annual renewal: 1 year
4. Treatment of moderate to severe active Crohn’s disease or fistulizing Crohn’s disease	First approval (induction period): 12 weeks Annual renewal: 1 year

Practitioner Exemptions

• None

Forms

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

• Adalimumab/Etanercept/Infliximab and Abatacept/Rituximab for Rheumatoid Arthritis-Initial or Switching Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Rheumatoid Arthritis-Annual Renewal (PDF)
• Rheumatoid Arthritis Functional Assessment Form (PDF)
• Adalimumab/Etanercept/Infliximab for Psoriatic Arthritis-Initial Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Psoriatic Arthritis-Renewal Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Ankylosing Spondylitis-Initial Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Ankylosing Spondylitis-Renewal Coverage (PDF)
• Adalimumab/Infliximab for Moderate to Severe Active Crohn’s Disease or Fistulizing Crohn’s Disease (PDF)
• BASDAI (Bath Ankylosing Spondylitis-Disease Activity Index) (PDF)
• Worksheet (based on Harvey Bradshaw Index) (PDF)

Last Revised: September 09, 2008