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Hulio (adalimumab-fkjp) — Blue Cross Blue Shield of Montana

moderately to severely active rheumatoid arthritis (RA)

Preferred products

  • Humira (adalimumab)
  • 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 the following are eligible for continuation of therapy: Abrilada, Adalimumab-ryvk, Amjevita, Cyltezo (adalimumab-adbm), Hulio (adalimumab-fkjp), Hyrimoz, Idacio (adalimumab-aacf), Yuflyma, and Yusimry
  • 1. If the requested agent is NOT a preferred agent, the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days [chart notes required] AND is at risk if therapy is changed [chart notes required] OR 2. If the requested agent is a preferred agent, the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR B. ALL of the following:
  • 1. The patient has an FDA labeled indication or a compendia-supported indication for the requested agent and route of administration AND ONE of the following diagnosis-specific criteria:
  • For rheumatoid arthritis: the patient has tried and had an inadequate response to methotrexate (titrated to 25 mg weekly) after ≥3 months OR has tried one conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) for ≥3 months OR intolerance/hypersensitivity to one conventional agent OR FDA-labeled contraindication to all conventional agents OR history of use of another biologic immunomodulator for RA.
  • For psoriatic arthritis: the patient has tried and had an inadequate response to ≥1 conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) for ≥3 months OR intolerance/hypersensitivity to one conventional agent OR FDA-labeled contraindication to all conventional agents OR severe active psoriasis (greater than 10% BSA, special locations, intractable pruritus, emotional impact) OR severe active PsA (erosive disease, elevated markers, functional damage, rapidly progressive) OR medication history indicates use of another biologic immunomodulator or Otezla appropriate for PsA.
  • For plaque psoriasis: the patient has tried and had an inadequate response to ≥1 conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA [phototherapy], tacrolimus, tazarotene, topical corticosteroids) for ≥3 months OR intolerance/hypersensitivity or contraindication to all such conventional agents.