Idacio — CareFirst (Caremark)

Initial criteria

• Rheumatoid arthritis (RA): adult member with moderately to severely active RA; meet biomarker testing (positive RF or anti-CCP, or tested for RF, anti-CCP, CRP and/or ESR); AND failed to achieve low disease activity after at least a 3‑month trial of methotrexate monotherapy at ≥15 mg/week OR intolerant/contraindicated to methotrexate; AND inadequate response or intolerance/contraindication to other conventional synthetic DMARDs (leflunomide, hydroxychloroquine, sulfasalazine) as applicable; OR previously received biologic/targeted synthetic DMARD for RA within past 120 days.
• Juvenile idiopathic arthritis (JIA): age ≥2 years; inadequate response to methotrexate or another conventional synthetic drug (leflunomide, sulfasalazine, hydroxychloroquine) at adequate dose and duration OR inadequate response to scheduled NSAIDs and/or intra-articular glucocorticoids with ≥1 poor prognostic factor (ankle, wrist, hip, sacroiliac, or TMJ involvement; erosive disease; delay in diagnosis; elevated inflammation markers; symmetric disease) OR has risk factors for severe course (high-risk joints, high disease activity, high risk for disabling disease).
• Psoriatic arthritis (PsA): adult member with active PsA who previously received a biologic or targeted synthetic drug (e.g. Rinvoq, Otezla) OR meets documentation requirements per policy.
• Ankylosing spondylitis, non-radiographic axial spondyloarthritis, hidradenitis suppurativa, uveitis, immune checkpoint inhibitor–related toxicity: chart notes documenting medications tried and response; may include documentation of reason therapy not advisable.
• Plaque psoriasis (PsO): documentation of affected body surface area and prior therapies; previous medications tried and response; if prior therapies not advisable, clinical reason to avoid therapy.
• Behcet’s disease, Pyoderma gangrenosum: documentation of previous medication trials and response (if applicable).
• Prescriber specialty requirement: must be prescribed by or in consultation with appropriate specialist (rheumatologist, dermatologist, gastroenterologist, ophthalmologist, oncologist/hematologist as indication‑specific).

Reauthorization criteria

• Rheumatoid arthritis, JIA, PsA, AS, nr‑axSpA, hidradenitis suppurativa, uveitis, immune checkpoint inhibitor–related toxicity: documentation of positive clinical response.
• Crohn’s disease, ulcerative colitis: documentation of positive clinical response or remission.
• Plaque psoriasis: documentation of decreased BSA affected and/or improvement in signs and symptoms.

Approval duration

12 months