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Humira (adalimumab) — Blue Cross Blue Shield of Texas

active psoriatic arthritis (PsA)

Preferred products

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

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), Humira, Hyrimoz, Idacio (adalimumab-aacf), Yuflyma, Yusimry
  • - If the requested agent is NOT a preferred agent, then 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 [chart notes required]
  • - If the requested agent is a preferred agent, then 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
  • B. ALL of the following:
  • 1. The patient has an FDA labeled indication or a 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. Tried and had an inadequate response to maximally tolerated methotrexate (titrated to 25 mg weekly) after at least a 3-month duration of therapy OR
  • 2. Tried and had an inadequate response to ONE conventional agent (hydroxychloroquine, leflunomide, sulfasalazine) after at least a 3-month duration OR
  • 3. Has an intolerance or hypersensitivity to ONE conventional agent (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 4. Has an FDA labeled contraindication to ALL conventional agents (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) OR
  • 5. Medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for RA
  • B. Diagnosis of active psoriatic arthritis (PsA) AND ONE of the following:
  • 1. Tried and had an inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after at least a 3-month duration OR
  • 2. Has intolerance or hypersensitivity to ONE conventional agent used in PsA OR
  • 3. Has an FDA labeled contraindication to ALL conventional agents used in PsA OR
  • 4. Has severe active PsA (e.g., erosive disease, elevated ESR/CRP, long-term damage that interferes with function, rapidly progressive) OR
  • 5. Has concomitant severe psoriasis (greater than 10% body surface area, select locations such as hands/feet/scalp/face/genitals, intractable pruritus, serious emotional consequences) OR
  • 6. Medication history indicates use of another biologic immunomodulator agent or Otezla that is FDA labeled or supported in compendia for PsA