ADALIMUMAB

ADALIMUMAB (12339K)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12339K
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 1 (new patient)

Restriction

Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 5 years)

Restriction

Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological medicine of more than 5 years)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 0 DPMQ: $2,015.19 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12372E)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12372E
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 1 (new patient)

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 5 years)

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological medicine of more than 5 years)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 0 DPMQ: $2,015.19 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12393G)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12393G
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Complex refractory Fistulising Crohn disease
Treatment phase: Initial treatment - Initial 1 (new patient or recommencement of treatment after a break in biological medicine of more than 5 years)

Restriction

Indication: Complex refractory Fistulising Crohn disease
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 5 years)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 0 DPMQ: $2,015.19 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12394H)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12394H
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial treatment - Initial 1, Whole body (new patient)

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial treatment - Initial 2, Whole body (change or recommencement of treatment after a break in biological medicine of less than 5 years)

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial treatment - Initial 3, Whole body (recommencement of treatment after a break in biological medicine of more than 5 years)

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial treatment - Initial 1, Face, hand, foot (new patient)

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial treatment - Initial 2, Face, hand, foot (change or recommencement of treatment after a break in biological medicine of less than 5 years)

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial treatment - Initial 3, Face, hand, foot (recommencement of treatment after a break in biological medicine of more than 5 years)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $677.59 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12395J)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12395J
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Moderate to severe hidradenitis suppurativa
Treatment phase: Initial 1 (new patient), Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 5 years), or Initial 3 (recommencement of treatment after a break in biological medicine of more than 5 years) - balance of supply
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 2 DPMQ: $1,346.38 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12408C)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12408C
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Moderate to severe hidradenitis suppurativa
Treatment phase: First continuing treatment

Restriction

Indication: Moderate to severe hidradenitis suppurativa
Treatment phase: Subsequent continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 5 DPMQ: $1,346.38 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12409D)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12409D
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 1 (new patient)

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 5 years)

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological medicine of more than 5 years)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 0 DPMQ: $2,015.19 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12524E)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
12524E
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Moderate to severe hidradenitis suppurativa
Treatment phase: Initial treatment - Initial 1 (new patient)

Restriction

Indication: Moderate to severe hidradenitis suppurativa
Treatment phase: Initial treatment - Initial 2 (Change or recommencement of treatment after a break in biological medicine of less than 5 years)

Restriction

Indication: Moderate to severe hidradenitis suppurativa
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological medicine of more than 5 years)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 0 DPMQ: $2,015.19 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (14622N)

adalimumab 80 mg/0.8 mL injection, 0.8 mL syringe
14622N
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 11529)

Indication: Moderate to severe hidradenitis suppurativa
Treatment phase: Subsequent continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 5 DPMQ: $1,346.38 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Yuflyma