Rinvoq — CareFirst (Caremark)

Initial criteria

• Member age ≥ 2 years
• Member has active polyarticular juvenile idiopathic arthritis
• Member achieves or maintains a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms when there is improvement from baseline in one or more of the following: number of joints with active arthritis (swelling, pain, limitation of motion), number of joints with limitation of movement, functional ability
• 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 a positive clinical response with improvement in number of affected joints or functional ability

Approval duration

12 months