Skip to content
The Policy VaultThe Policy Vault

Adalimumab-ryvk — Blue Cross Blue Shield of Texas

active psoriatic arthritis (PsA)

Preferred products

  • Adalimumab
  • Adalimumab-aaty
  • Amjevita (adalimumab-atto)
  • Cyltezo (adalimumab-adbm)
  • Hulio (adalimumab-fkjp)
  • Hyrimoz (adalimumab-adaz)
  • Idacio (adalimumab-aacf)
  • Yuflyma (adalimumab-aaty)
  • Yusimry (adalimumab-aqvh)
  • Simlandi (adalimumab-ryvk)
  • Hadlima (adalimumab-bwwd)
  • Humira (adalimumab)

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), Hyrimoz, Idacio (Adalimumab-aacf), Yuflyma, Yusimry
  • 1. If requested agent is NOT a preferred agent: prescriber states 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 [chart notes required] OR
  • 2. If requested agent is a preferred agent: prescriber states 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:
  • 1. Patient has an FDA labeled indication or compendia-supported indication for the requested agent and route of administration AND ONE of the following:
  • A. Diagnosis of moderately to severely active rheumatoid arthritis (RA) AND ONE of the following:
  • 1. Has tried and had inadequate response to maximally tolerated methotrexate (titrated to 25 mg weekly) after ≥ 3 months therapy OR
  • 2. Has tried and had inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, or sulfasalazine) after ≥ 3 months therapy OR
  • 3. Has intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 4. Has FDA labeled contraindication to ALL of methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine OR
  • 5. Medication history indicates use of another biologic immunomodulator approved for RA OR
  • B. Diagnosis of active psoriatic arthritis (PsA) AND ONE of the following:
  • 1. Has tried and had inadequate response to ONE conventional agent (e.g., cyclosporine, ... text continues)