Tyenne subcutaneous — Medica

Preferred products

• Enbrel
• adalimumab-adbm
• adalimumab-adaz
• adalimumab-ryvk
• Simlandi

Initial criteria

• Patient meets the standard Inflammatory Conditions – Tocilizumab Subcutaneous Prior Authorization Policy criteria
• AND meets ONE of the following:
• Polyarticular Juvenile Idiopathic Arthritis: tried one adalimumab product OR trial of Enbrel, Cimzia, infliximab product, or Simponi Aria also counts
• Rheumatoid Arthritis: tried one adalimumab product OR trial of Cimzia, Enbrel, infliximab product, or Simponi (Aria or subcutaneous) also counts
• OR According to the prescriber, patient has heart failure or a previously treated lymphoproliferative disorder
• OR According to the prescriber, patient has been established on tocilizumab intravenous or subcutaneous for at least 90 days and verified by claims or prescriber

Reauthorization criteria

• Continue to meet the standard Inflammatory Conditions – Tocilizumab Subcutaneous Prior Authorization Policy criteria

Approval duration

1 year