adalimumab products — Cigna

Initial criteria

• Patient age ≥ 18 years; AND
• Patient meets ONE of the following (a or b):
• a) Patient meets BOTH of the following [(1) and (2)]:
• (1) Patient has arthritis primarily in the knees, ankles, elbows, wrists, hands, and/or feet; AND
• (2) Patient has tried at least one conventional synthetic disease-modifying antirheumatic drug (DMARD) (e.g., methotrexate, leflunomide, sulfasalazine); OR
• b) Patient has axial spondyloarthritis AND has objective signs of inflammation, defined as at least ONE of the following [(1) or (2)]:
• (1) C-reactive protein elevated beyond the upper limit of normal for the reporting laboratory; OR
• (2) Sacroiliitis reported on magnetic resonance imaging (MRI); AND
• Medication is prescribed by or in consultation with a rheumatologist.

Reauthorization criteria

• Patient has been established on therapy for at least 6 months; AND
• Patient meets at least ONE of the following (a or b):
• a) When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (prior to initiating an adalimumab product); OR
• b) Compared with baseline (prior to initiating an adalimumab product), patient experienced an improvement in at least one symptom, such as decreased pain or stiffness, or improvement in function or activities of daily living.

Approval duration

initial 6 months; reauth 1 year