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Humira — CareFirst (Caremark)

ulcerative colitis

Initial criteria

  • Rheumatoid arthritis (RA): adult member with moderately to severely active RA; biomarker testing (RF and/or anti-CCP, CRP/ESR) documented; and member meets one of the following: (a) failed to achieve low disease activity after ≥3 month trial of methotrexate at ≥15 mg/week with combination DMARDs (hydroxychloroquine, sulfasalazine) unless contraindicated or not tolerated; OR (b) unable to tolerate methotrexate and failed other conventional DMARDs (leflunomide, hydroxychloroquine, sulfasalazine) at adequate trial unless contraindicated; OR (c) has intolerance or contraindication to methotrexate with failure or intolerance to other conventional DMARDs; AND has moderate to high disease activity.
  • Juvenile idiopathic arthritis (JIA): member age ≥2 years with moderately to severely active disease and one of the following: inadequate response to methotrexate or other conventional synthetic drug (leflunomide, sulfasalazine, hydroxychloroquine) at adequate dose/duration; OR inadequate response to scheduled NSAIDs and/or intra-articular glucocorticoids with risk factor for poor outcome (involvement of ankle, wrist, hip, sacroiliac, TMJ, erosive disease, enthesitis, delayed diagnosis, elevated inflammation markers, symmetric disease); OR high-risk joints (cervical spine, wrist, hip) or high disease activity or risk for disabling joint disease.
  • Psoriatic arthritis (PsA): adult member with active disease who has previously received biologic or targeted synthetic drug (e.g., Rinvoq, Otezla) indicated for PsA or meets step therapy per criteria applied later in document.
  • Other indications listed (AS, PsO, HS, UC, CD, uveitis, Behcet’s disease, pyoderma gangrenosum, etc.) referred but detailed criteria appear in subsequent pages not in this chunk.

Reauthorization criteria

  • Rheumatoid arthritis: positive clinical response documented in chart notes.
  • JIA: positive clinical response documented in chart notes.
  • PsA and other indications: positive clinical response documented in chart notes or decreased symptoms per disease-specific measures.

Approval duration

12 months