adalimumab — CareFirst (Caremark)

Rheumatoid arthritis (RA)

Initial criteria

Adult member with moderately to severely active rheumatoid arthritis
If previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Xeljanz) indicated for RA within the past 120 days, approval may be granted
If no prior biologic or targeted synthetic drug, both of the following must be met:
Member meets either biomarker requirement:
Member tested positive for rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP)
OR Member tested for all of RF, anti-CCP, and C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR)
AND one of the following therapy criteria:
Failed to achieve low disease activity after a 3‑month trial of methotrexate (MTX) monotherapy ≥15 mg/week and had inadequate response to or intolerable adverse event/contraindication to hydroxychloroquine or sulfasalazine; or moderate/high disease activity
Unable to tolerate a 3‑month MTX trial ≥15 mg/week and had inadequate response to or intolerable adverse event/contraindication to leflunomide, hydroxychloroquine, or sulfasalazine; or moderate/high disease activity
Experienced intolerable adverse event or contraindication to MTX and had inadequate response to or intolerable adverse event/contraindication to leflunomide, hydroxychloroquine, or sulfasalazine; or moderate/high disease activity

Chart notes or medical record documentation supporting positive clinical response

12 months