Rinvoq — CareFirst (Caremark)

Initial criteria

• Member has moderately to severely active Crohn’s disease
• Member achieves or maintains remission OR has a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition when there is improvement from baseline in one or more of the following: Abdominal pain or tenderness, Diarrhea, Body weight, Abdominal mass, Hematocrit, Appearance of the mucosa on endoscopy, CTE, MRE, or intestinal ultrasound, Improvement on a disease activity scoring tool (e.g., CDAI score)
• Member has a documented negative tuberculosis (TB) test (tuberculosis skin test [TST] or interferon-release assay [IGRA]) within 12 months prior to initiating therapy for persons naïve to biologic or targeted synthetic drugs associated with increased TB risk
• If TB test is positive, additional testing must confirm no active disease; do not administer if active TB; latent TB must be treated before initiation
• Requested medication is not used concomitantly with any other biologic drug, targeted synthetic drug, or potent immunosuppressant such as azathioprine or cyclosporine

Reauthorization criteria

• Member continues to achieve or maintain remission OR continues to have a positive clinical response with evidence of low disease activity or improvement in signs and symptoms as measured by criteria listed above

Approval duration

12 months