Limited Coverage Drugs – adalimumab
Last updated on August 7, 2024
Return to Special Authority drug list
Generic name |
adalimumab |
|
|---|---|---|
Brand name |
Strength |
Form |
| Abrilada | 20 mg/0.4 mL | pre-filled syringe |
| 40 mg/0.8 mL | pre-filled syringe pre-filled pen |
|
| Amgevita | 20 mg/0.4 mL | pre-filled syringe |
| 40 mg/0.8 mL | pre-filled syringe autoinjector |
|
| Hadlima | 40 mg/0.4 mL | autoinjector pre-filled syringe |
| 40 mg/0.8 mL | pre-filled syringe autoinjector |
|
| Hulio | 20 mg/0.4 mL | pre-filled syringe |
| 40 mg/0.8 mL | pre-filled syringe autoinjector |
|
| Hyrimoz | 20 mg/ 0.2 mL | pre-filled syringe |
| 40 mg/ 0.4 mL | pre-filled syringe autoinjector |
|
| 80 mg/0.8 mL | pre-filled syringe autoinjector |
|
| 20 mg/0.4 mL | pre-filled syringe | |
| 40 mg/0.8 mL | pre-filled syringe autoinjector |
|
| Idacio | 40 mg/0.8 mL | pre-filled syringe pre-filled pen |
| Simlandi | 40 mg/0.4 mL | pre-filled syringe autoinjector |
| 80 mg/0.8 mL | pre-filled syringe | |
| Yuflyma | 40 mg/0.4 mL | pre-filled syringe pre-filled pen |
| 80 mg/0.8mL | pre-filled syringe pre-filled pen |
|
Special Authority criteria |
Approval period |
|---|---|
|
Treatment of rheumatoid arthritis according to established criteria1 when prescribed by a rheumatologist |
|
|
Treatment of ankylosing spondylitis according to established criteria1 when prescribed by a rheumatologist |
|
|
Treatment of psoriatic arthritis according to established criteria1 when prescribed by a rheumatologist |
|
|
Treatment of moderate to severe plaque psoriasis, according to established criteria1 when prescribed by a dermatologist |
|
|
Treatment of moderate to severe active polyarticular juvenile idiopathic arthritis for patients 2 years and older who, due to intolerance or lack of efficacy, have not adequately responded to methotrexate |
|
|
Treatment of adult patients with active moderate to severe hidradenitis suppurativa according to established criteria1 prescribed by a dermatologist |
|
|
Treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease2, according to established criteria1 when prescribed by a gastroenterologist |
|
|
Treatment of moderate to severe ulcerative colitis, according to criteria1 prescribed by a gastroenterologist |
|
Practitioner exemptions
- Pediatric rheumatologists for pediatric patients diagnosed with polyarticular juvenile idiopathic arthritis (pJIA)
Special notes
- 1Established criteria are explained in the Special Authority forms below
- 2Hadlima, Simlandi and Yuflyma are currently not indicated for pediatric CD
- PharmaCare covers a maximum 28-day supply of adalimumab per fill
Special Authority requests
Log in to eForms to view criteria and submit an online request.
Rheumatoid arthritis
- HLTH 5345 – Targeted DMARDs for rheumatoid arthritis: Initial/switch (PDF, 862KB)
- HLTH 5354 – Targeted DMARDs for rheumatoid arthritis: Renewal/dosing adjustment(PDF, 911KB)
- HLTH 5383 – Health assessment questionnaire (HAQ) (PDF, 528KB)
Ankylosing spondylitis
- HLTH 5364 – Bath ankylosing spondylitis - disease activity index (BASDAI) (PDF, 64KB)
- HLTH 5365 – Targeted DMARDs for ankylosing spondylitis: Initial/switch (PDF, 812KB)
- HLTH 5366 – Targeted DMARDs for ankylosing spondylitis: Renewal/dosing adjustment (PDF, 872KB)
Crohn’s disease
- HLTH 5368 – Biologics for moderate to severe active Crohn's or fistulizing Crohn's disease: Initial/switch (PDF, 1.2MB)
- HLTH 5495 – Biologics for moderate to severe active Crohn's or fistulizing Crohn's disease: Renewal/dosing adjustment(PDF, 1.3MB)
- HLTH 5374 – Worksheet (based on Harvey Bradshaw Index) (PDF, 514KB)
Hidradenitis suppurativa
Psoriatic arthritis
- HLTH 5360 – Targeted DMARDs for psoriatic arthritis: Initial/switch (PDF, 812KB)
- HLTH 5361 – Targeted DMARDs for psoriatic arthritis: Renewal/dosing adjustment (PDF, 856KB)
- HLTH 5364 – Bath ankylosing spondylitis - disease activity index (BASDAI) (PDF, 64KB)
- HLTH 5383 – Health assessment questionnaire (HAQ) (PDF, 528KB)
Plaque psoriasis
- HLTH 5380 – Biologics for moderate to severe psoriasis (PDF, 830KB)
- HLTH 5379 – Psoriasis area and severity index (PASI) worksheet (PDF, 529KB)
Ulcerative colitis