Adalimumab (Humira, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Simlandi, Yuflyma, Yusimry, Abrilada, adalimumab-afzb, adalimumab-aacf, adalimumab-adaz, adalimumab-adbm, adalimumab-fkjp, adalimumab-bwwd, adalimumab-ato, adalimumab-aqvh, adalimumab-ryvk, adalimumab-aaty) — United Healthcare

Initial criteria

• Diagnosis of moderately to severely active rheumatoid arthritis
• History of failure to a 3 month trial of one non-biologic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) at maximally indicated doses unless contraindicated or clinically significant adverse effects are experienced OR Patient previously treated with a biologic or targeted immunomodulator FDA-approved for rheumatoid arthritis OR Patient currently on adalimumab therapy and has not received manufacturer supplied sample or manufacturer sponsored program assistance
• Patient is not receiving adalimumab in combination with another targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, Orencia, Xeljanz, Olumiant, Rinvoq)
• Prescribed by or in consultation with a rheumatologist

Reauthorization criteria

• Documentation of positive clinical response to adalimumab therapy
• Patient is not receiving adalimumab in combination with another targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, Orencia, Xeljanz, Olumiant, Rinvoq)

Approval duration

12 months