biologic immunomodulator agents for rheumatoid arthritis (RA) — Blue Cross Blue Shield of Illinois

Initial criteria

• Request is NOT for Olumiant or Actemra for treatment of COVID-19 in hospitalized adults
• ONE of the following: (A) agent eligible for continuation and prescriber states patient treated with agent within past 90 days (not samples) AND is at risk if therapy changed OR (B) patient has FDA labeled or compendia supported indication and route
• For RA: ONE of the following: (A) inadequate response to maximally tolerated methotrexate after ≥3 months OR inadequate response to one conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) after ≥3 months OR intolerance or hypersensitivity to one of the listed conventional agents OR (B) FDA labeled contraindication to all conventional agents OR (C) medication history indicating use of another biologic immunomodulator for RA
• If request is for Simponi, then ONE of: (A) Simponi will be used in combination with methotrexate OR (B) intolerance, hypersensitivity, or FDA labeled contraindication to methotrexate