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The Policy VaultThe Policy Vault

Cyltezo (adalimumab-adbm) — Blue Cross Blue Shield of Alabama

active ankylosing spondylitis (AS)

Preferred products

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

Initial criteria

  • ONE of the following:
  • The requested agent is eligible for continuation of therapy AND ONE of the following:
  • Agents eligible for continuation of therapy: all target agents EXCEPT listed non-eligible agents
  • Patient has been treated with the requested agent (samples not approvable) within past 90 days OR prescriber attests to such treatment and patient is at risk if changed
  • OR ALL of the following:
  • Patient has an FDA labeled indication or compendia-supported indication AND ONE of the following condition-specific sets:
  • - Rheumatoid arthritis: inadequate response to methotrexate titrated up to 25 mg weekly for ≥3 months OR inadequate response to one conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) for ≥3 months OR intolerance/hypersensitivity/contraindication to these OR medication history with another biologic immunomodulator for RA
  • - Psoriatic arthritis: inadequate response to one conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) for ≥3 months OR intolerance/hypersensitivity/contraindication to these OR severe active PsA (erosive disease, elevated inflammation markers, long-term damage, rapidly progressive) OR concomitant severe psoriasis (criteria specified) OR medication history with another biologic or Otezla
  • - Plaque psoriasis: inadequate response to one conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA, tacrolimus, tazarotene, topical corticosteroids) for ≥3 months OR intolerance/hypersensitivity/contraindication to these OR severe active PS (greater than 10% BSA or involving special sites or serious effects) OR concomitant severe PsA OR medication history with another biologic or Otezla
  • - Crohn’s disease: inadequate response to one conventional agent (6-mercaptopurine, azathioprine, corticosteroids, methotrexate) for ≥3 months OR intolerance/hypersensitivity/contraindication to these OR medication history with another biologic immunomodulator for CD
  • - Ulcerative colitis: inadequate response to one conventional agent (6-mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) for ≥3 months OR intolerance/hypersensitivity/contraindication to these OR severely active UC OR medication history with another biologic immunomodulator for UC
  • - Non-infectious intermediate uveitis/posterior/panuveitis: inadequate response/intolerance/contraindication to one oral or periocular/intravitreal corticosteroid OR both classes AND inadequate response/intolerance/contraindication to one conventional systemic agent (azathioprine, mycophenolate, methotrexate, cyclosporine, tacrolimus) OR medication history with another biologic immunomodulator for the condition
  • - Ankylosing spondylitis: inadequate response to two different NSAIDs used in treatment of AS after ≥4-week total duration