requested agent — Blue Cross Blue Shield of Illinois

psoriatic arthritis (PsA)

Preferred products

The request is NOT for use of Olumiant or Actemra in the treatment of COVID-19 in hospitalized adults requiring oxygen or ventilation
EITHER the requested agent is eligible for continuation of therapy OR the patient has an FDA labeled or compendia-supported indication for the requested agent and route of administration
If continuation of therapy: the patient has been treated with the requested agent within the past 90 days (not samples) and is at risk if therapy is changed
For rheumatoid arthritis (RA):
– ONE of the following:
• Inadequate response to maximally tolerated methotrexate after ≥3 months
• Inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) after ≥3 months
• Intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine)
• FDA labeled contraindication to ALL conventional agents
• Medication history indicates use of another biologic immunomodulator FDA labeled or compendia supported for RA
AND if Simponi requested, the patient will use with methotrexate OR has intolerance, contraindication, or hypersensitivity to methotrexate
For psoriatic arthritis (PsA): ONE of the following (criteria continues beyond excerpt)

Patient previously approved through the plan’s Prior Authorization process
Patient has had clinical benefit with the requested agent
If preferred agents exist: either the requested agent is preferred OR the patient meets ONE of the following:
A. Diagnosed with stage IV advanced metastatic cancer and requested agent treats the cancer or associated condition per FDA and literature support
B. Currently treated with and stable on the requested agent
C. Tried and had inadequate response to THREE preferred agents after ≥6 months each
D. Discontinued THREE preferred agents due to lack of efficacy/effectiveness, diminished effect, or adverse event
E. Has intolerance/hypersensitivity to THREE preferred agents not expected with requested agent
F. Has FDA labeled contraindication to ALL preferred agents not expected with requested agent
G. THREE preferred agents expected to be ineffective or unsafe based on patient characteristics
H. THREE preferred agents not in best interest of patient based on medical necessity
I. Tried another drug in same class/mechanism as THREE preferred agents and discontinued due to inefficacy/adverse event
Prescriber is or has consulted a relevant specialist
Requested agent not used with another immunomodulatory agent unless prescribing information allows and combination use is supported by evidence
No FDA labeled contraindications to the requested agent

12 months