Enbrel — CareFirst (Caremark)

Initial criteria

• Authorization of 1 month may be granted for treatment of immune checkpoint inhibitor-related toxicity when the member has Stevens-Johnson syndrome or toxic epidermal necrolysis.
• Authorization of 12 months may be granted for treatment of immune checkpoint inhibitor-related toxicity when the member has moderate or severe immunotherapy-related inflammatory arthritis and either of the following is met:
• Member has had an inadequate response to corticosteroids or a conventional synthetic drug (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine).
• Member has an intolerance or contraindication to corticosteroids and a conventional synthetic drug (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine).

Reauthorization criteria

• Authorization of 12 months may be granted for all members (including new members) who are using the requested medication for immunotherapy-related inflammatory arthritis and who achieve or maintain a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition.

Approval duration

12 months (1 month if SJS/TEN)