Simponi — Blue Cross Blue Shield of Oklahoma

Initial criteria

• For RA: patient’s medication history indicates use of another biologic immunomodulator agent FDA labeled or supported for RA AND if Simponi requested, patient will take with methotrexate OR has intolerance, contraindication, or hypersensitivity to methotrexate.
• For PsA: diagnosis of active disease AND ANY of the following: (1) inadequate response to ≥1 conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after ≥3 months OR intolerance/hypersensitivity to one conventional agent OR contraindication to all conventional agents OR severe active PsA OR concomitant severe psoriasis OR prior biologic immunomodulator or Otezla use.
• For PS: diagnosis of moderate to severe plaque psoriasis AND ANY of the following: (1) inadequate response to ≥1 conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar, cyclosporine, methotrexate, pimecrolimus, PUVA, tacrolimus, tazarotene, topical corticosteroids) after ≥3 months OR intolerance/hypersensitivity to one conventional agent OR contraindication to all OR severe active psoriasis OR concomitant severe PsA OR prior biologic immunomodulator or Otezla use.
• For CD: diagnosis of moderately to severely active CD AND ANY of the following: currently stable on requested agent OR inadequate response to ≥1 conventional agent (6-mercaptopurine, azathioprine, corticosteroids, methotrexate) after ≥3 months OR discontinued due to inefficacy or adverse event OR intolerance/hypersensitivity to one conventional agent OR contraindication to all OR conventional agent expected ineffective or not in best interest OR prior biologic immunomodulator use.
• For UC: diagnosis of moderately to severely active UC AND ANY of the following: currently stable on requested agent OR inadequate response to ≥1 conventional agent (6-mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) ≥3 months OR discontinued due to inefficacy/adverse event OR intolerance/hypersensitivity OR contraindication to all OR conventional agent expected ineffective/not in best interest OR severely active UC OR prior biologic immunomodulator use.
• For non-infectious intermediate, posterior, or panuveitis: diagnosis confirmed AND ANY of the following: (1) BOTH: inadequate response to OR intolerance/contraindication to oral or periocular/intravitreal corticosteroid AND inadequate response to OR intolerance/contraindication to conventional systemic agent (azathioprine, mycophenolate, methotrexate, cyclosporine, tacrolimus), or severe active sight-threatening disease OR prior biologic immunomodulator use.
• For GCA: diagnosis confirmed AND ANY of the following: inadequate response to systemic corticosteroid (prednisone, methylprednisolone) ≥7 days OR intolerance/hypersensitivity OR contraindication to all corticosteroids OR prior biologic immunomodulator use.
• For AS: diagnosis confirmed AND ANY of the following: inadequate response to two NSAIDs after ≥4 weeks total OR inadequate response to one NSAID ≥4 weeks plus intolerance/hypersensitivity to another OR intolerance to two NSAIDs OR contraindication to all OR prior biologic immunomodulator use.
• For nr-axSpA: diagnosis confirmed AND ONE of the following (criteria continues on next page).