Simponi — CareFirst (Caremark)

Initial criteria

• Member is using the requested medication for immunotherapy-related inflammatory arthritis
• Member achieves or maintains a positive clinical response with the requested medication as evidenced by low disease activity or improvement in signs and symptoms of the condition
• Member has had a documented negative tuberculosis (TB) test (tuberculosis skin test [TST] or interferon-release assay [IGRA]) within 12 months of initiating therapy for persons naïve to biologic drugs or targeted synthetic drugs associated with increased risk of TB
• If TB screening is positive, further testing confirms no active disease (e.g., chest x-ray)
• Do not administer the requested medication to members with active TB infection
• If there is latent TB disease, TB treatment must be started before initiation of the requested medication
• Member cannot use the requested medication concomitantly with any other biologic drug or targeted synthetic drug for the same indication

Reauthorization criteria

• Member continues to achieve or maintain a positive clinical response with the requested medication as evidenced by low disease activity or improvement in signs and symptoms of the condition

Approval duration

12 months