Cimzia — CareFirst (Caremark)

Initial criteria

• Member age ≥ 2 years
• Member previously received a biologic or targeted synthetic drug (e.g., Xeljanz) indicated for pJIA OR any of the following:
• Inadequate response to methotrexate or another conventional DMARD (leflunomide, sulfasalazine, or hydroxychloroquine) at adequate dose and duration
• Inadequate response to trial of scheduled NSAIDs and/or intra-articular glucocorticoids (e.g., triamcinolone hexacetonide) plus risk factor(s) for poor outcome including: ankle, wrist, hip, sacroiliac, or TMJ involvement, erosive disease, enthesitis, delayed diagnosis, elevated inflammatory markers, or symmetric disease
• High risk for severe disease or disabling joint disease: high-risk joints (cervical spine, wrist, or hip) involved OR high disease activity OR judged high risk for disabling joint disease

Reauthorization criteria

• Positive clinical response documented in chart or medical records.

Approval duration

12 months