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The Policy VaultThe Policy Vault

Adalimumab-aacf — Blue Cross Blue Shield of Illinois

moderate to severe plaque psoriasis (PS)

Preferred products

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

Initial criteria

  • ONE of the following: A. The requested agent is eligible for continuation of therapy AND ONE of the following: Agents Eligible for Continuation of Therapy - All target agents EXCEPT specified are eligible for continuation
  • If the requested agent is NOT a preferred agent, prescriber states patient has been treated with the requested agent (not samples) within past 90 days AND is at risk if therapy is changed
  • If the requested agent is a preferred agent, prescriber states patient has been treated with the requested agent (not samples) within past 90 days AND is at risk if therapy is changed
  • OR B. ALL of the following: patient has FDA labeled indication or compendia supported indication for requested agent and route AND ONE of the following indication-specific criteria:
  • For rheumatoid arthritis (RA): patient has tried and had inadequate response to methotrexate ≥3 months OR inadequate response to one conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) ≥3 months OR intolerance/hypersensitivity to one conventional agent OR contraindication to all conventional agents OR medication history of another biologic immunomodulator for RA
  • For psoriatic arthritis (PsA): patient has tried and had inadequate response to one conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) ≥3 months OR intolerance/hypersensitivity to one conventional agent OR contraindication to all conventional agents OR severe active PS features (≥10% BSA or sensitive areas or intractable pruritus/emotional consequences) OR severe active PsA (erosive, elevated inflammation markers, long-term functional damage, rapidly progressive) OR medication history of another biologic immunomodulator or Otezla for PsA
  • For plaque psoriasis (PS): patient 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