Skip to content
The Policy VaultThe Policy Vault

Adalimumab-aacf — Blue Cross Blue Shield of Illinois

psoriatic arthritis

Preferred products

  • Adalimumab-aaty
  • Adalimumab-adbm
  • Adalimumab-ryvk
  • Amjevita (adalimumab-atto)
  • Cyltezo (adalimumab-adbm)
  • 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 Abrilada, Adalimumab-ryvk, Amjevita, Cyltezo (adalimumab-adbm), Hulio (adalimumab-fkjp), Humira, Hyrimoz, Idacio (adalimumab-aacf), Yuflyma, Yusimry are eligible for continuation; OR (B) ALL of the following:
  • – The patient has an FDA labeled or compendia-supported indication for the requested agent and route of administration AND
  • Diagnosis of moderately to severely active rheumatoid arthritis AND ONE of the following:
  • • Tried and had inadequate response to maximally tolerated methotrexate (up to 25 mg weekly) for ≥3 months OR
  • • Tried and had inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) for ≥3 months OR
  • • Intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • • FDA labeled contraindication to ALL conventional agents (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • • Medication history indicates use of another biologic immunomodulator FDA labeled or compendia-supported for RA
  • OR Diagnosis of active psoriatic arthritis AND ONE of the following:
  • • Tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) for ≥3 months OR
  • • Intolerance or hypersensitivity to ONE conventional agent used for PsA OR
  • • FDA labeled contraindication to ALL conventional agents used for PsA OR
  • • Severe active PsA (e.g., erosive disease, elevated markers, long-term functional damage, rapidly progressive) OR
  • • Concomitant severe psoriasis (greater than 10% BSA, or on sensitive sites, or serious emotional/pruritic impact) OR
  • • Medication history indicates use of another biologic immunomodulator agent or Otezla for PsA