adalimumab — CareFirst (Caremark)

Initial criteria

• Rheumatoid arthritis (RA): Adult member with moderately to severely active RA AND laboratory confirmation using either positive rheumatoid factor (RF) or positive anti-cyclic citrullinated peptide (anti-CCP) OR testing of RF, anti-CCP, and CRP and/or ESR. Member must have failed to achieve low disease activity after a 3‑month trial of methotrexate monotherapy ≥15 mg per week OR was unable to tolerate a 3‑month trial of methotrexate, OR has a contraindication/intolerable adverse event to methotrexate, and also has had inadequate response, intolerance, or contraindication to at least one other conventional synthetic disease-modifying drug (leflunomide, hydroxychloroquine, sulfasalazine). Moderate to high disease activity required.
• Juvenile idiopathic arthritis (JIA, polyarticular): Member age ≥ 2 years. Member has moderately to severely active disease AND either (1) inadequate response to methotrexate or another conventional synthetic drug (leflunomide, sulfasalazine, hydroxychloroquine) at adequate dose and duration OR (2) inadequate response to non-steroidal anti-inflammatory drugs (NSAIDs) and/or intra-articular glucocorticoids and has at least one poor‑prognosis factor (ankle, wrist, hip, sacroiliac, or TMJ involvement; erosive disease; enthesitis; delayed diagnosis; high inflammatory markers; symmetric disease) OR (3) has risk factors for severe disease (cervical spine, wrist, or hip involvement, or high disease activity or judged high risk for disabling disease).
• Psoriatic arthritis (PsA): Adult member with active PsA. Authorization may be granted if member previously received a biologic or targeted synthetic DMARD (e.g., Rinvoq or Otezla) indicated for PsA OR meets standard plan step‑therapy criteria (failing conventional therapy, as detailed in later portion of policy).
• For all diagnoses: Initial submission must include chart notes or medical documentation supporting previous medications tried (if applicable) and response, or a clinical reason other therapy is inadvisable.

Reauthorization criteria

• Rheumatoid arthritis (RA), JIA, PsA, AS, nraxSpA, hidradenitis suppurativa, uveitis, and immune‑checkpoint‑related arthritis: Chart notes or medical record documentation supporting positive clinical response.
• Crohn’s disease (CD) and ulcerative colitis (UC): Chart notes or medical documentation supporting positive clinical response or remission.
• Plaque psoriasis (PsO): Chart notes or medical record documentation showing decreased body surface area affected and/or improvement in signs and symptoms.

Approval duration

12 months