adalimumab-bwwd — CareFirst (Caremark)

Initial criteria

• Member age ≥ 2 years (for uveitis)
• Requested medication is used for an indication outlined in the coverage criteria section
• Member has a documented negative tuberculosis (TB) test within 12 months of initiating therapy for persons naïve to biologic or targeted synthetic drugs associated with increased TB risk
• If TB screening is positive, further testing confirms no active disease (e.g., chest x-ray)
• Do not administer requested medication to members with active TB infection
• If latent TB disease is present, TB treatment must be started before initiation of requested medication
• Member is not using the requested medication concomitantly with any other biologic drug or targeted synthetic drug for the same indication
• For rheumatoid arthritis: member must initiate treatment with every other week dosing

Reauthorization criteria

• Uveitis: Member continues to achieve or maintain a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms, meeting any of the following:
• • Reduced frequency of disease flares compared to baseline
• • Stability or improvement in anterior chamber (AC) cell grade compared to baseline
• • Stability or improvement in vitreous haze (VH) grade compared to baseline
• • Stability or improvement in visual acuity compared to baseline
• • Reduction in glucocorticoid requirements from baseline
• • No new active inflammatory chorioretinal and/or inflammatory retinal vascular lesions relative to baseline
• Immune checkpoint inhibitor-related inflammatory arthritis: Member achieves or maintains a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms
• All other covered indications: Member achieves or maintains a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms

Approval duration

12 months