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Adalimumab-adbm — Blue Cross Blue Shield of Texas

Moderate to severe plaque psoriasis (PS)

Preferred products

  • Adalimumab
  • Adalimumab-atto (Amjevita)

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 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, then the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days [chart notes required] AND is at risk if therapy is changed.
  • If the requested agent is a preferred agent, then the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed.
  • OR (B) ALL of the following: 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:
  • For rheumatoid arthritis: ONE of the following applies: (1) Tried and had inadequate response to maximally tolerated methotrexate (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; OR (5) Has medication history indicating use of another biologic immunomodulator labeled or supported for RA.
  • For psoriatic arthritis: ONE of the following applies: (1) Tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after ≥3 months; OR (2) Has intolerance or hypersensitivity to ONE conventional agent; OR (3) Has FDA labeled contraindication to ALL conventional agents; OR (4) Has severe active psoriasis (e.g., >10% BSA, hands/feet/scalp/face/genitals, intractable pruritus, serious emotional consequences); OR (5) Has severe active PsA (erosive disease, elevated ESR/CRP, long-term damage impacting function, rapidly progressive); OR (6) Medication history indicates use of another biologic immunomodulator or Otezla labeled or supported for PsA.
  • For plaque psoriasis: ONE of the following applies: (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) after ≥3 months; OR (2) Has intolerance, hypersensitivity, or contraindication to conventional agents.