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The Policy VaultThe Policy Vault

Adalimumab-aacf — Blue Cross Blue Shield of New Mexico

moderately to severely active rheumatoid arthritis (RA)

Preferred products

  • Adalimumab
  • Adalimumab-aaty
  • Adalimumab-adaz
  • Adalimumab-aacf
  • Adalimumab-adbm
  • Adalimumab-fkjp
  • Adalimumab-ryvk
  • Hadlima (adalimumab-bwwd)
  • Humira (adalimumab)
  • 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, Hyrimoz, Idacio, Adalimumab-aacf, Yuflyma, Yusimry.
  • If the requested agent is NOT a preferred agent, then 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].
  • If the requested agent is a preferred agent, then 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.
  • B. ALL of the following:
  • 1. The patient has an FDA labeled indication or an indication supported in compendia for the requested agent and route of administration AND ONE of the following disease criteria:
  • A. For rheumatoid arthritis (RA):
  • 1. The patient has tried and had an inadequate response to maximally tolerated methotrexate (e.g., titrated to 25 mg weekly) after ≥3 months of therapy OR
  • 2. The patient has tried and had an inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) after ≥3 months of therapy OR
  • 3. The patient has an intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 4. The patient has an FDA labeled contraindication to ALL conventional agents (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 5. The patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for RA.
  • B. For psoriatic arthritis (PsA):
  • 1. The patient has tried and had an inadequate response to ONE conventional agent (e.g., cyclosporine).