target agents (see step table) — Blue Cross Blue Shield of Alabama

Preferred products

• Adalimumab-aaty
• Adalimumab-adaz
• Hadlima
• Humira (preferred for current utilizers only)
• Simlandi
• Selarsdi
• Steqeyma
• Stelara
• Yesintek

Initial criteria

• The request is NOT for use of Olumiant or Actemra for treatment of COVID-19 in hospitalized adults requiring supplemental oxygen, ventilation, or ECMO
• If the request is for alopecia areata, coverage must not be restricted under patient’s benefit
• ONE of the following:
• The requested agent is eligible for continuation of therapy AND ONE of the following:
• • Patient has been treated with the requested agent (not trial of samples) within the past 90 days OR
• • Prescriber states patient has been treated within last 90 days and is at risk if therapy is changed
• OR ALL of the following:
• • Patient has an FDA labeled or compendia-supported indication and route of administration AND
• • For rheumatoid arthritis (RA):
•  – Has tried and had an inadequate response to methotrexate (titrated to 25 mg weekly) ≥3 months OR
•  – Has tried and had an inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) ≥3 months OR
•  – Has intolerance/hypersensitivity to ONE conventional agent OR
•  – Has contraindication to ALL conventional agents OR
•  – Medication history shows use of another biologic immunomodulator labeled/supported for RA
•  AND if request is for Simponi: patient will use methotrexate in combination OR has intolerance/hypersensitivity/contraindication to methotrexate
• • For psoriatic arthritis (PsA):
•  – Has tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) ≥3 months OR
•  – Has intolerance/hypersensitivity to ONE conventional agent OR
•  – Has contraindication to ALL conventional agents OR
•  – Has severe active PsA OR concomitant severe psoriasis OR
•  – Medication history indicates use of another biologic immunomodulator agent or Otezla supported/labeled for PsA
• • For psoriasis (PS):
•  – Has tried and had inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA, tacrolimus, tazarotene, topical corticosteroids) ≥3 months OR
•  – Has intolerance/hypersensitivity or contraindication to these conventional agents
• If client has preferred agents, then preferred agent must be tried per table unless contraindicated or intolerant (see step requirements below)
• If ustekinumab requested for CD or UC, patient received or will receive IV induction with ustekinumab
• If ustekinumab 90 mg requested, patient meets weight/diagnosis criteria (>100 kg with psoriasis or dual PsA/PS, or has CD/UC)
• Prescriber is a specialist in the related field or has consulted one
• Patient not using concurrently with other immunomodulators unless permitted by prescribing info and supported by evidence
• Patient tested for latent TB and treated if positive
• Patient has no FDA-labeled contraindications
• Supported by AHFS, DrugDex 1 or 2a, or NCCN 1 or 2a

Reauthorization criteria

• Patient previously approved through plan PA process
• Patient experienced clinical benefit
• If client has preferred agents, step therapy per preferred table applies (same as initial)
• Prescriber is specialist or has consulted specialist
• Patient not using with another immunomodulator unless allowed and supported
• Patient has no FDA-labeled contraindications

Approval duration

12 months