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Abrilada (adalimumab-afzb) — Blue Cross Blue Shield of Montana

active psoriatic arthritis (PsA)

Preferred products

  • Adalimumab
  • Adalimumab-aaty (Yuflyma)
  • Adalimumab-adaz (Hyrimoz)
  • Adalimumab-aacf (Idacio)
  • Adalimumab-adbm (Cyltezo)
  • Adalimumab-fkjp (Hulio)
  • Adalimumab-ryvk (Simlandi)
  • Adalimumab-atto (Amjevita)
  • adalimumab-bwwd (Hadlima)
  • adalimumab-aqvh (Yusimry)

Initial criteria

  • 1. 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), Hyrimoz, Idacio (adalimumab-aacf), Yuflyma, Yusimry
  • • If the requested agent is NOT a preferred agent, then prescriber states the patient has been treated with the requested agent (not samples) within the past 90 days [chart notes required] AND is at risk if therapy is changed [chart notes required]
  • • If the requested agent is a preferred agent, then prescriber states the patient has been treated with the requested agent (not samples) within the past 90 days AND is at risk if therapy is changed
  • OR
  • B. All of the following:
  • 1. Patient has an FDA labeled indication or indication supported in compendia for requested agent and route of administration AND
  • One of the following:
  • A. Patient has diagnosis of moderately to severely active rheumatoid arthritis (RA) AND one of:
  • • Tried and had inadequate response to maximally tolerated methotrexate (titrated to 25 mg weekly) after at least 3 months of therapy
  • • Tried and had inadequate response to one conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) used for RA after at least 3 months of therapy
  • • Has intolerance or hypersensitivity to one conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine)
  • • Has an FDA labeled contraindication to all of the following conventional agents: methotrexate, hydroxychloroquine, leflunomide, sulfasalazine
  • • Medication history indicates use of another biologic immunomodulator agent FDA labeled or supported in compendia for treatment of RA
  • OR
  • B. Patient has diagnosis of active psoriatic arthritis (PsA) AND one of the following:
  • • Tried and had inadequate response to one conventional agent (cyclosporine, etc.)