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The Policy VaultThe Policy Vault

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

active psoriatic arthritis (PsA)

Preferred products

  • Adalimumab
  • Amjevita (adalimumab-atto)
  • Cyltezo (adalimumab-adbm)
  • Hulio (adalimumab-fkjp)
  • Hyrimoz (adalimumab-adaz)
  • Idacio (adalimumab-aacf)

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: 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, prescriber must state patient has been treated with the requested agent (starting on samples is not approvable) within past 90 days [chart notes required] AND is at risk if therapy is changed [chart notes required] OR if requested agent is a preferred agent, prescriber must state patient has been treated within 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 an indication supported in compendia for the requested agent and route of administration.
  • AND ONE of the following:
  • A. For moderately to severely active rheumatoid arthritis (RA): ONE of the following must apply: 1. Tried and had inadequate response to maximally tolerated methotrexate (e.g., titrated 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 4. Has FDA-labeled contraindication to ALL conventional agents listed, OR 5. Medication history indicates use of another biologic immunomodulator agent FDA labeled or compendia supported for treatment of RA.
  • B. For active psoriatic arthritis (PsA): patient has tried and had inadequate response to ONE conventional agent (e.g., cyclosporine ...)