Olumiant (baricitinib) — United Healthcare

Rheumatoid Arthritis (RA)

Preferred products

Diagnosis of moderately to severely active RA
AND one of the following:
- 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 (document drug, date, and duration of trial)
- OR patient has been previously treated with a targeted immunomodulator FDA-approved for the treatment of RA (document drug, date, and duration of therapy) [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Rinvoq (upadacitinib)]
AND one of the following:
- History of failure, contraindication, or intolerance to two of the following preferred products (document drug, date, and duration of trial): one preferred adalimumab product, Cimzia, Enbrel, Rinvoq, Simponi, Xeljanz/Xeljanz XR
- OR both: patient is currently on Olumiant therapy (document drug, date, and duration) AND patient has not received a manufacturer supplied sample or other Eli Lilly assistance (e.g., Olumiant Together program) as a means to establish current use
AND patient is not receiving Olumiant in combination with either of the following:
- Targeted immunomodulator [e.g., Enbrel, Cimzia, Simponi, Orencia, adalimumab, Xeljanz, Rinvoq]
- Potent immunosuppressant (e.g., azathioprine or cyclosporine)
AND prescribed by or in consultation with a rheumatologist

Documentation of positive clinical response to Olumiant therapy
AND patient is not receiving Olumiant in combination with either of the following:
- Targeted immunomodulator [e.g., Enbrel, Cimzia, Simponi, Orencia, adalimumab, Xeljanz, Rinvoq]
- Potent immunosuppressant (e.g., azathioprine or cyclosporine)

12 months