Orencia — CareFirst (Caremark)

Initial criteria

• Adult member
• Authorization of 12 months may be granted for adult members who have previously received a biologic or targeted synthetic drug indicated for moderately to severely active RA within the past 120 days OR both of the following are met:
• Member meets either of the following biomarker criteria: (a) tested positive for rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP); OR (b) tested for RF, anti-CCP, CRP and/or ESR
• Member meets ONE of the following treatment history criteria:
• — Failed to achieve low disease activity after 3‑month trial of methotrexate (MTX) monotherapy ≥15 mg/week and meets any of: inadequate response to MTX + hydroxychloroquine and/or sulfasalazine; intolerable adverse event to hydroxychloroquine or sulfasalazine; contraindication to hydroxychloroquine and sulfasalazine (porphyria, intestinal or urinary obstruction); or moderate/high disease activity
• — Unable to tolerate 3‑month MTX trial and meets any of: inadequate response to MTX + hydroxychloroquine and/or sulfasalazine; inadequate response to another csDMARD (leflunomide, hydroxychloroquine, and/or sulfasalazine) alone or in combination; intolerable adverse event to leflunomide, hydroxychloroquine, or sulfasalazine; contraindication to these drugs; or moderate/high disease activity
• — Experienced intolerable adverse event or contraindication to MTX, discontinued MTX, and meets any of: inadequate response to another csDMARD (leflunomide, hydroxychloroquine, and/or sulfasalazine); intolerable adverse event to these agents; contraindication to leflunomide, hydroxychloroquine, and sulfasalazine; or moderate/high disease activity

Reauthorization criteria

• Authorization of 12 months may be granted for adult members who achieve or maintain a positive clinical response as evidenced by ≥20% improvement from baseline in tender joint count, swollen joint count, pain, or disability

Approval duration

12 months