Cosentyx — Highmark
Polyarticular juvenile idiopathic arthritis (PJIA)
Preferred products
- Enbrel
- adalimumab (preferred formulations per Table 2: Cyltezo, Hyrimoz, Simlandi, adalimumab-adbm [00597], adalimumab-adaz, Amjevita, Idacio, Hadlima, Hulio, Humira [83457 labeler], Hyrimoz [83457 labeler], Yuflyma, Yusimry)
- Taltz
- Skyrizi
- Otezla
- Sotyktu
- Ustekinumab (preferred formulations per Table 2: Stelara SC, Yesintek SC, ustekinumab-aekn, ustekinumab-ttwe, Wezlana SC, Steqeyma SC)
- Tremfya
- Omvoh
- Cosentyx
- Cimzia (for CD, UC)
- Actemra SC (preferred tocilizumab)
- Omvoh (UC, CD)
- Taltz (nr-axSpA, HS)
Initial criteria
- Coverage is based on Step Therapy per Table 1: member must have tried and had insufficient response, contraindication, or intolerance to required preferred product(s) for the indication before approval of any non-preferred product.
- For Step 2a agents (Rinvoq tablets, Xeljanz/Xeljanz XR/oral solution, tocilizumab SC, Olumiant): must have a trial of at least one Step 1 preferred agent (as directed in the Step 1 column for the same indication).
- For Step 2b agents (Bimzelx): must have a trial of one Step 1 preferred agent for the same indication.
- For Step 3a agents (Cimzia, Kevzara, Kineret, Olumiant, Orencia, Simponi, Simponi Aria, Cosentyx, Ilumya, Siliq): must have trials of two Step 1 and/or Step 2a preferred agents for the same indication.
- For Step 3b agent (Zeposia): must have trials of two Step 1 agents for the defined indication.
- Directed requirements apply per footnotes: adalimumab-specific, Enbrel or adalimumab, Cimzia-specific, and tocilizumab- or ustekinumab-specific trials as listed in Table 1 notes.
- Documentation of preferred product trials (chart notes, prescription records, or receipts) must be provided when required (footnote 7).