Skip to content
The Policy VaultThe Policy Vault

Amjevita — Blue Cross Blue Shield of Alabama

moderate to severe hidradenitis suppurativa (HS)

Preferred products

  • adalimumab-aaty
  • adalimumab-adaz
  • Hadlima (adalimumab-bwwd)
  • Simlandi (adalimumab-ryvk)

Initial criteria

  • Requested agent is eligible for continuation of therapy if patient has been treated with it within the past 90 days (starting on samples not approvable) or prescriber states patient has been treated within past 90 days and is at risk if changed
  • Otherwise, patient must have an FDA labeled or compendia-supported indication and route, AND meet disease-specific requirements:
  • Rheumatoid arthritis: tried and inadequate response to methotrexate (≥3 months) OR inadequate response/intolerance/contraindication to ≥1 conventional DMARD (hydroxychloroquine, leflunomide, sulfasalazine) OR use of another biologic immunomodulator labeled for RA.
  • Psoriatic arthritis: inadequate response/intolerance/contraindication to ≥1 conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after ≥3 months OR severe active disease or concomitant severe psoriasis OR use of another biologic or Otezla labeled for PsA.
  • Plaque psoriasis: inadequate response/intolerance/contraindication to ≥1 conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar, cyclosporine, methotrexate, pimecrolimus, PUVA, tacrolimus, tazarotene, topical corticosteroids) after ≥3 months OR severe active PS or concomitant severe PsA OR use of another biologic or Otezla labeled for PS.
  • Crohn’s disease: inadequate response/intolerance/contraindication to ≥1 conventional agent (6-mercaptopurine, azathioprine, corticosteroids, methotrexate) after ≥3 months OR use of another biologic immunomodulator labeled for CD.
  • Ulcerative colitis: inadequate response/intolerance/contraindication to ≥1 conventional agent (6-mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) after ≥3 months OR severely active UC OR use of another biologic immunomodulator labeled for UC.
  • Noninfectious intermediate/posterior/panuveitis: inadequate response/intolerance/contraindication to oral or periocular/intravitreal corticosteroid (≥2 weeks) AND inadequate response/intolerance/contraindication to ≥1 conventional systemic agent (azathioprine, mycophenolate, methotrexate, cyclosporine, tacrolimus) after ≥3 months OR use of another biologic labeled for uveitis.
  • Ankylosing spondylitis: inadequate response/intolerance/contraindication to ≥2 different NSAIDs (≥4 weeks total) OR use of another biologic labeled for AS.
  • Non-radiographic axial spondyloarthritis: inadequate response/intolerance/contraindication to ≥2 different NSAIDs (≥4 weeks total) OR use of another biologic labeled for nr-axSpA.
  • Polyarticular juvenile idiopathic arthritis: inadequate response/intolerance/contraindication to ≥1 conventional agent (methotrexate, leflunomide) after ≥3 months OR use of another biologic labeled for PJIA.