biologic immunomodulator agents — Blue Cross Blue Shield of Illinois

Initial criteria

• 1. The patient has tried and had an inadequate response to methotrexate (e.g., 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 of therapy OR has an intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine)
• 2. The patient has an FDA‑labeled contraindication to ALL 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 RA
• B. ONE of the following: The patient will be using a conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) in combination with the requested agent OR the patient has an intolerance, hypersensitivity, or FDA‑labeled contraindication to ALL conventional agents (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine)

Approval duration

12 months