Cimzia — CareFirst (Caremark)

Initial criteria

• Adult member
• Member has previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Xeljanz) indicated for moderately to severely active rheumatoid arthritis within the past 120 days OR all of the following:
• Member tested for biomarkers and results per below:
• • Either positive rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP), OR tested for RF, anti-CCP, and C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR)
• AND meets ONE of the following:
• 1. Failed to achieve low disease activity after a 3-month trial of methotrexate monotherapy at ≥15 mg/week AND (a) inadequate response to MTX + hydroxychloroquine and/or sulfasalazine; OR (b) intolerable adverse event to hydroxychloroquine or sulfasalazine; OR (c) contraindication to hydroxychloroquine and sulfasalazine (e.g., porphyria, intestinal or urinary obstruction); OR moderate to high disease activity.
• 2. Unable to tolerate a 3-month trial of methotrexate ≥15 mg/week AND (a) inadequate response to MTX + other conventional drugs (leflunomide, hydroxychloroquine, or sulfasalazine) at tolerated doses; OR (b) inadequate response to another conventional drug alone/combination; OR (c) intolerable adverse event to leflunomide, hydroxychloroquine, or sulfasalazine; OR (d) contraindication to these drugs; OR moderate to high disease activity.
• 3. Experienced intolerable adverse event or had contraindication to methotrexate, discontinued MTX, AND either (a) inadequate response to another conventional synthetic DMARD alone/combination; OR (b) intolerable adverse event to those DMARDs; OR (c) contraindication to leflunomide, hydroxychloroquine, and sulfasalazine; OR (d) moderate to high disease activity.

Reauthorization criteria

• Positive clinical response, as evidenced by chart notes or medical records.

Approval duration

12 months