adalimumab-aqvh — CareFirst (Caremark)

Initial criteria

• Member age ≥2 years
• If previously received a biologic or targeted synthetic drug (e.g., Xeljanz) indicated for moderately to severely active JIA, approval may be granted
• Otherwise, one of the following:
• Inadequate response to methotrexate or another conventional synthetic drug (e.g., leflunomide, sulfasalazine, hydroxychloroquine) administered at adequate dose and duration
• Inadequate response to scheduled NSAIDs and/or intra-articular glucocorticoids (e.g., triamcinolone hexacetonide) and one risk factor for poor outcome such as ankle, wrist, hip, sacroiliac, or TMJ involvement; erosive disease or enthesitis; delay in diagnosis; elevated inflammation markers; or symmetric disease
• Presence of risk factors for disease severity per Appendix B and either high-risk joint involvement (cervical spine, wrist, or hip), high disease activity, or judged high risk for disabling joint disease

Reauthorization criteria

• Chart notes or medical record documentation supporting positive clinical response

Approval duration

12 months