Rinvoq tablets — Highmark
Crohn’s Disease (CD)
Preferred products
- Enbrel
- adalimumab (preferred biosimilars per Table 2: Cyltezo, Hyrimoz, Simlandi, adalimumab-adaz, adalimumab-adbm, Amjevita, Idacio, Hadlima, Hulio, Humira [00074 labeler], Hyrimoz [61314 labeler], Yuflyma, Yusimry)
- Taltz
- Skyrizi
- Tremfya
- Ustekinumab (SC)
- Otezla
- Cimzia (for CD, UC, nr-axSpA)
- Cosentyx (for nr-axSpA, HS)
Initial criteria
- Coverage requires a trial and failure, contraindication, or intolerance to the indicated Step 1 preferred product(s) for the relevant disease state as shown in Table 1.
- Step 2a non-preferred products are directed to ONE Step 1 agent trial; Step 3a products require TWO Step 1 or 2a agent trials as applicable.
- Documentation of prior trials must be provided, which may include chart notes, prescription claims records, and/or prescription receipts.
- For tocilizumab subcutaneous use in PJIA, member must have trial of adalimumab first.
- A trial of any preferred adalimumab product counts as one adalimumab preferred product.
- A trial of any preferred tocilizumab or ustekinumab product counts as one preferred product for that drug.