Enbrel (etanercept) — CareFirst (Caremark)

Initial criteria

• Age ≥ 2 years
• Member has inadequate response to methotrexate or another conventional synthetic drug (e.g., leflunomide, sulfasalazine, hydroxychloroquine) administered at adequate dose and duration; OR
• Member has inadequate response to a trial of scheduled non-steroidal anti-inflammatory drugs (NSAIDs) and/or intra-articular glucocorticoids and has ≥1 risk factor for poor outcome (e.g., involvement of ankle/wrist/hip/sacroiliac/TMJ, erosive disease, enthesitis, delayed diagnosis, elevated inflammatory markers, symmetric disease); OR
• Member has high-risk joints involved (e.g., cervical spine, wrist, or hip), high disease activity, or judged at high risk for disabling joint disease

Reauthorization criteria

• Chart notes or medical record documentation supporting positive clinical response

Approval duration

12 months