Simponi ARIA — Blue Cross Blue Shield of Oklahoma

rheumatoid arthritis (RA)

Initial criteria

Patient has an FDA labeled indication or compendia-supported indication for RA and route of administration
Patient has diagnosis of moderately to severely active RA
Has tried and had an inadequate response to maximally tolerated methotrexate (titrated to 25 mg weekly) after at least 3 months OR has tried and had an inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) for at least 3 months OR has intolerance/hypersensitivity to ONE conventional agent OR has FDA labeled contraindication to ALL conventional agents OR medication history indicates prior biologic immunomodulator for RA
If request is for Simponi ARIA, ONE of the following: will use methotrexate in combination OR has intolerance/hypersensitivity/contraindication to methotrexate
Prescriber is a relevant specialist or has consulted one
Agent not used concomitantly with another immunomodulator unless permitted and supported
Requested dose within FDA labeled or compendia dosing, or meets high-dose titration criteria

Previously approved through plan’s prior authorization process
Clinical benefit shown
Conditions 3A–3K met regarding preferred agents, cancer use, stability, or failure/intolerance/contraindication to preferred agents
Prescriber specialist involvement
No contraindications
Dose within limits

12 months