Tremfya (guselkumab) — CareFirst (Caremark)

Initial criteria

• Member age ≥ 18 years
• Medication prescribed by or in consultation with a rheumatologist or dermatologist
• Member has had a documented negative tuberculosis (TB) test (TST or IGRA) within 12 months prior to initiating therapy; if positive, further testing confirms no active disease and latent TB is treated before starting Tremfya
• Member will not use Tremfya concomitantly with any other biologic drug or targeted synthetic drug for the same indication
• Member has previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Otezla) indicated for active psoriatic arthritis OR
• Member has mild to moderate disease and meets one of the following:
• Inadequate response to methotrexate, leflunomide, or another conventional synthetic drug (e.g., sulfasalazine) administered at an adequate dose and duration
• Intolerance or contraindication to methotrexate, leflunomide, or another conventional synthetic drug (e.g., sulfasalazine)
• Member has enthesitis OR has severe disease

Reauthorization criteria

• Authorization of 12 months may be granted for members using Tremfya for psoriatic arthritis who achieve or maintain a positive clinical response as evidenced by improvement in one or more of the following from baseline:
• Number of swollen joints
• Number of tender joints
• Dactylitis
• Enthesitis
• Skin and/or nail involvement
• Functional status
• C-reactive protein (CRP)

Approval duration

12 months