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The Policy VaultThe Policy Vault

Humira (adalimumab) — Blue Cross Blue Shield of Montana

active psoriatic arthritis (PsA)

Preferred products

  • Adalimumab-aaty
  • Adalimumab-adaz
  • Adalimumab-aacf
  • 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 Abrilada, Adalimumab-ryvk, Amjevita, Cyltezo, Adalimumab-adbm, Hulio, Adalimumab-fkjp, Humira, Hyrimoz, Idacio, Adalimumab-aacf, Yuflyma, Yusimry; OR (1) If the requested agent is NOT a preferred agent, the prescriber states the patient has been treated with the requested agent within past 90 days (samples not approvable) AND is at risk if therapy is changed; OR (2) If the requested agent is a preferred agent, the prescriber states the patient has been treated with the requested agent within past 90 days (samples not approvable) AND is at risk if therapy is changed.
  • (B) ALL of the following: The patient has an FDA labeled indication or compendia-supported indication for the requested agent and route of administration, AND ONE of the following conditions:
  • — Diagnosis of moderately to severely active rheumatoid arthritis (RA) AND ONE of the following: (1) Tried and had inadequate response to maximally tolerated methotrexate (titrated up to 25 mg weekly) after ≥ 3 months; OR (2) Tried and had inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) after ≥ 3 months; OR (3) Has intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine); OR (2) Has FDA labeled contraindication to ALL conventional agents used in RA; OR (3) Medication history indicates use of another biologic immunomodulator agent FDA labeled or supported for RA.
  • — Diagnosis of active psoriatic arthritis (PsA) AND ONE of the following: (1) Tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after ≥ 3 months; OR (2) Intolerance or hypersensitivity to ONE conventional agent used in PsA; OR (3) FDA labeled contraindication to ALL conventional agents used in PsA; OR (4) Severe active PsA (e.g., erosive disease, elevated inflammatory markers ESR/CRP attributable to PsA, long-term damage interfering with function, rapidly progressive); OR (5) Concomitant severe psoriasis (greater than 10% body surface area or involving hands, feet, scalp, face, genitals, or having intractable pruritus or serious emotional consequences); OR (6) Medication history indicates use of another biologic immunomodulator or Otezla that is FDA labeled for treatment of PsA.