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Adalimumab-aacf — Blue Cross Blue Shield of Illinois

moderately to severely active rheumatoid arthritis (RA)

Preferred products

  • Adalimumab
  • Adalimumab-aaty
  • Adalimumab-adaz
  • Adalimumab-aacf
  • Amjevita (adalimumab-atto)
  • Cyltezo (adalimumab-adbm)
  • Hulio (adalimumab-fkjp)
  • Hyrimoz (adalimumab-adaz)
  • Idacio (adalimumab-aacf)
  • Simlandi (adalimumab-ryvk)

Initial criteria

  • The requested agent is eligible for continuation of therapy AND ONE of the following: Agents Eligible for Continuation of Therapy: All target agents EXCEPT Abrilada, Adalimumab-ryvk, Amjevita, Cyltezo (Adalimumab-adbm), Hulio (Adalimumab-fkjp), Hyrimoz, Idacio (Adalimumab-aacf), Yuflyma, and Yusimry are eligible for continuation of therapy.
  • If the requested agent is NOT a preferred agent, then the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days [chart notes required] AND is at risk if therapy is changed [chart notes required] OR
  • If the requested agent is a preferred agent, then the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR
  • The patient has an FDA labeled indication or an indication supported in compendia for the requested agent and route of administration AND ONE of the following:
  • For rheumatoid arthritis (RA): ONE of the following: Has tried and had an inadequate response to maximally tolerated methotrexate (titrated to 25 mg weekly) after at least a 3-month duration of therapy OR Has tried and had an inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) after at least a 3-month duration OR Has an intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR The patient has an FDA labeled contraindication to ALL the following conventional agents (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR The patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of RA.
  • For psoriatic arthritis (PsA): ONE of the following: Has tried and had an inadequate response to ONE conventional agent (cyclosporine, ...)