Enbrel (etanercept) — Highmark
Ankylosing spondylitis (AS)
Initial criteria
- For RA: age ≥18 years; diagnosis of moderate to severe RA; prescribed by or in consultation with a rheumatologist; therapeutic failure or intolerance to at least one non-biologic DMARD (methotrexate, leflunomide, sulfasalazine, cyclosporine) or all non-biologic DMARDs contraindicated
- For AS: age ≥18 years; diagnosis of AS; prescribed by or in consultation with a rheumatologist
- For PJIA: age ≥2 years; diagnosis of moderate to severe PJIA; prescribed by or in consultation with a rheumatologist; and (i) therapeutic failure or intolerance to at least one non-biologic DMARD or all non-biologic DMARDs contraindicated OR (ii) requires initial biologic therapy due to involvement of high-risk joints, high disease activity, or high risk of disabling joint damage
- For PsA with spinal or axial disease: age ≥2 years; diagnosis of spinal or axial PsA; prescribed by or in consultation with a rheumatologist or dermatologist; therapeutic failure or intolerance to at least one NSAID or all NSAIDs contraindicated
- For PsA without spinal or axial disease: age ≥2 years; diagnosis of PsA without spinal disease; prescribed by or in consultation with a rheumatologist or dermatologist; therapeutic failure or intolerance to at least one non-biologic DMARD or all non-biologic DMARDs contraindicated
- For enthesitis and/or dactylitis associated PsA: age ≥2 years; diagnosis of enthesitis and/or dactylitis associated with PsA; prescribed by or in consultation with a rheumatologist or dermatologist; therapeutic failure or intolerance to at least one NSAID or local glucocorticoid injection or all NSAIDs and local glucocorticoid injections contraindicated
- For PsO: age ≥4 years; diagnosis of moderate to severe PsO; prescribed by or in consultation with a dermatologist or rheumatologist; and one of the following: (i) therapeutic failure or intolerance to phototherapy, (ii) therapeutic failure or intolerance to at least one systemic therapy (for example, methotrexate), or (iii) contraindicated to both phototherapy and systemic therapy
Reauthorization criteria
- Member has demonstrated disease stability or a beneficial response to therapy