Skip to content
The Policy VaultThe Policy Vault

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

Rheumatoid arthritis (RA)

Preferred products

  • Adalimumab-aaty
  • Adalimumab-adaz
  • Adalimumab-aacf
  • Adalimumab-ryvk

Initial criteria

  • 1. 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.
  • 1. If the requested agent is NOT a preferred agent, prescriber states patient has been treated with the requested agent (not samples) within 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 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 compendia-supported indication for the requested agent and route of administration AND ONE of the following indication-based criteria:
  • A. Moderately to severely active rheumatoid arthritis (RA) AND ONE of:
  • 1. Tried and had inadequate response to maximally tolerated methotrexate for ≥3 months OR
  • 2. Tried and had inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) used in RA for ≥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 (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 5. Medication history indicates use of another biologic immunomodulator agent FDA labeled or compendia supported for RA.
  • B. Active psoriatic arthritis (PsA) AND ONE of:
  • 1. Tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) for ≥3 months OR
  • 2. Has intolerance or hypersensitivity to ONE conventional agent used in PsA OR
  • 3. Has FDA labeled contraindication to ALL conventional agents used in PsA OR
  • 4. Has severe active PsA (e.g., erosive disease, elevated inflammatory markers, long-term functional damage, rapidly progressive) OR
  • 5. Has concomitant severe psoriasis (e.g., >10% BSA, hands/feet/scalp/face/genitals involvement, intractable pruritus, serious emotional consequences) OR
  • 6. Medication history indicates use of another biologic immunomodulator or Otezla FDA labeled for PsA.