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The Policy VaultThe Policy Vault

Cyltezo (adalimumab-adbm) — Blue Cross Blue Shield of Oklahoma

active psoriatic arthritis (PsA)

Preferred products

  • Adalimumab
  • Adalimumab-aaty
  • Adalimumab-adaz
  • Adalimumab-aacf
  • Adalimumab-atto
  • Adalimumab-bwwd
  • Adalimumab-fkjp
  • Adalimumab-ryvk
  • Humira
  • 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:
  • 1. If the requested agent is NOT a preferred agent, prescriber states 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] OR
  • 2. If the requested agent is a preferred agent, prescriber states 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. 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-specific conditions:
  • A. For rheumatoid arthritis (RA): patient has ONE of the following:
  • 1. Tried and had inadequate response to maximally tolerated methotrexate (titrated to 25 mg weekly) for ≥3 months OR
  • 2. Tried and had inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) for ≥3 months OR
  • 3. Intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 4. FDA labeled contraindication to ALL conventional agents (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 5. Medication history indicates use of another biologic immunomodulator for RA
  • B. For psoriatic arthritis (PsA): patient has ONE of the following:
  • 1. Tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) for ≥3 months OR
  • 2. Intolerance or hypersensitivity to ONE conventional agent OR
  • 3. FDA labeled contraindication to ALL conventional agents used in PsA OR
  • 4. Severe active psoriasis as defined (e.g., >10% BSA, special locations, intractable pruritus, serious emotional consequences) OR
  • 5. Severe active PsA as defined (erosive disease, elevated inflammatory markers, long-term functional damage, rapidly progressive) OR
  • 6. Medication history indicates use of another biologic immunomodulator or Otezla (apremilast) for PsA
  • C. For plaque psoriasis (PS): patient has ONE of the following:
  • 1. Tried and had inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA/phototherapy, tacrolimus, tazarotene, topical corticosteroids) for ≥3 months