ADALIMUMAB

ADALIMUMAB (12371D)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
12371D
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)

Restriction

Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial 1 (new patient) or 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: 1 Max qty units: 2 # of repeats: 3 DPMQ: $606.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12406Y)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
12406Y
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial treatment - Initial 1 (new patient)

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 12 months)

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological medicine of more than 12 months)

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial 1 (new patient) or Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 12 months) or Initial 3 (recommencement of treatment after a break in biological medicine of more than 12 months) - balance of supply
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $545.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12407B)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
12407B
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

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

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial 2 (change or recommencement of treatment after a break in targeted therapy of less than 12 months)

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial 3 (recommencement of treatment after a break in targeted therapy of more than 12 months)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 3 DPMQ: $606.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12423W)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
12423W
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe Crohn disease
Treatment phase: Balance of supply
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $606.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (12443X)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
12443X
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial treatment - Initial 1 (new patient)

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 12 months)

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological medicine of more than 12 months)

Restriction

Indication: Severe active juvenile idiopathic arthritis
Treatment phase: Initial 1 (new patient) or Initial 2 (change or recommencement of treatment after a break in biological medicine of less than 12 months) or Initial 3 (recommencement of treatment after a break in biological medicine of more than 12 months) - balance of supply
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $576.75 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (14245R)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
14245R
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Vision threatening non-infectious uveitis
Treatment phase: Balance of Supply
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $606.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (14976F)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
14976F
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial 1 treatment (Whole body) - biological medicine-naive patient

Restriction

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

Restriction

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

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Balance of supply - Initial 1, 2 or 3 treatment (Whole body, or, face/hand/foot)

Restriction

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

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Initial 2 treatment (Face, hand, foot) - Change of treatment, 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: 1 Max qty units: 2 # of repeats: 4 DPMQ: $606.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma

ADALIMUMAB (15148G)

adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes
15148G
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Enthesitis/spondylitis related juvenile idiopathic arthritis
Treatment phase: Initial treatment

Restriction

Indication: Enthesitis/spondylitis related juvenile idiopathic arthritis
Treatment phase: Initial treatment - balance of supply
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 3 DPMQ: $606.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Humira
Yuflyma