Erelzi — Medical Mutual

Initial criteria

• Patient age ≥ 2 years
• Patient has tried at least one conventional therapy (corticosteroids, immunosuppressants, interferon alfa) OR has already had trial of one biologic other than requested drug
• Medication prescribed by or in consultation with rheumatologist, dermatologist, ophthalmologist, gastroenterologist, or neurologist
• Site of care medical necessity is met

Reauthorization criteria

• Patient established on etanercept therapy ≥ 3 months
• Beneficial clinical response on objective measures (e.g., visual acuity, serum markers, ulcer/lesion size)
• Improvement in at least one symptom (e.g., decreased pain, improved acuity)
• Site of care medical necessity is met

Approval duration

initial 3 months, reauth 1 year