Enbrel (etanercept) — CareFirst (Caremark)
Moderately to severely active rheumatoid arthritis (RA)
Initial criteria
- Age ≥ 18 years
- Member meets either of the following biomarker conditions: (a) tested for rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP) and result positive; OR (b) tested for all biomarkers RF, anti-CCP, and C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR)
- Member meets ONE of the following: (a) failed 3-month trial of methotrexate (MTX) monotherapy at ≥15 mg/week and had inadequate response to or intolerance/contraindication to hydroxychloroquine and/or sulfasalazine; OR (b) unable to tolerate MTX and had inadequate response to or intolerance/contraindication to leflunomide, hydroxychloroquine, or sulfasalazine; OR (c) has contraindications to MTX, leflunomide, hydroxychloroquine, and sulfasalazine
- Member has moderate to high disease activity
Reauthorization criteria
- Chart notes or medical record documentation supporting positive clinical response
Approval duration
12 months