Enbrel — Medical Mutual

Initial criteria

• Patient age > 18 years
• If peripheral arthritis, patient has tried ≥1 DMARD OR If axial SpA, objective signs of inflammation shown by elevated CRP OR MRI
• Medication prescribed by or in consultation with rheumatologist
• Site of care medical necessity is met

Reauthorization criteria

• Patient established on therapy ≥ 6 months
• Beneficial clinical response per objective measure (e.g., ASDAS, CRP, ESR) OR improved symptoms (pain, stiffness, function)
• Site of care medical necessity is met

Approval duration

initial 6 months, reauth 1 year