Limited Coverage Drugs – adalimumab

Last updated on August 7, 2024

 

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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

  • First approval: 1 year
  • Renewal: 1 year to indefinite

Treatment of ankylosing spondylitis according to established criteria1 when prescribed by a rheumatologist

  • First approval: 1 year
  • Renewal: 1 year to indefinite

 Treatment of psoriatic arthritis according to established criteria1 when prescribed by a rheumatologist

  • First approval: 1 year
  • Renewal: 1 year to indefinite

Treatment of moderate to severe plaque psoriasis, according to established criteria1 when prescribed by a dermatologist

  • First approval: 16 weeks
  • Renewal: 1 year

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

  • Approval: 1 year

Treatment of adult patients with active moderate to severe hidradenitis suppurativa according to established criteria1 prescribed by a dermatologist

  • First approval: 6 months
  • Renewal: 1 year

Treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease2, according to established criteria1 when prescribed by a gastroenterologist

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

Treatment of moderate to severe ulcerative colitis, according to criteria1 prescribed by a gastroenterologist

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

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

Ankylosing spondylitis

Crohn’s disease

Hidradenitis suppurativa

Psoriatic arthritis

Plaque psoriasis

Ulcerative colitis