1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
|
|
- Philomena Merritt
- 5 years ago
- Views:
Transcription
1 LENGTH OF AUTHORIZATION: Initial: 3 months for Crohn s or Ulcerative Colitis; 1 year for all other indications. Renewal: 1 year dependent upon medical records supporting response to therapy and review of Rx history. * Prior approval will only be granted for the approved FDA indications listed below. * Must be prescribed by a rheumatologist, gastroenterologist or dermatologist based on the approved FDA indication Routine PDL edit plus Drug FDA Approved Indications Criteria for Approval Actemra (tocilizumab) Rheumatoid Arthritis (RA) (1.1) Adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs (DMARDs). Polyarticular Juvenile Idiopathic Arthritis (PJIA) (1.2) Patients 2 years of age and older with active polyarticular juvenile idiopathic arthritis. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis. Tried and failed Methotrexate; OR requested medication will be chronic liver disease, or other contraindication); AND Patient has tried and failed another DMARD (other than Methotrexate), such as azathioprine, d-penicillamine, cyclophosphamide, cyclosporine, gold salts, hydroxychloroquine, leflunomide, sulfasalazine, or tacrolimus; Tried and failed Methotrexate; OR requested medication will be chronic liver disease, or other contraindication); AND Patient has tried and failed another DMARD (other than Methotrexate), such as azathioprine, d-penicillamine, cyclophosphamide, cyclosporine, gold salts, hydroxychloroquine, leflunomide, sulfasalazine, or tacrolimus; Tried and failed Methotrexate; OR requested medication will be chronic liver disease, or other contraindication); AND Patient has tried and failed another DMARD (other than Methotrexate), such as azathioprine, d-penicillamine, cyclophosphamide, cyclosporine, gold salts, hydroxychloroquine, leflunomide, sulfasalazine, or tacrolimus; 1 P a g e
2 Cimzia (certolizumab) Reducing signs and symptoms of Crohn s disease and maintaining clinical response in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy Moderately to severely active RA in combination with methotrexate Psoriatic arthritis Trial and failure of a compliant regimen of oral corticosteroids (moderate to severe CD) unless contraindicated or intravenous corticosteroids (severe and fulminant CD or failure to respond to oral corticosteroids), AND Trial and failure of a compliant regimen of azathioprine or mercaptopurine for three consecutive months, AND Trial and failure of a compliant regimen of parenteral methotrexate for three consecutive months hydroxychloroquine, minocycline) Trial and failure of Methotrexate; OR requested medication will be chronic liver disease, or other contraindication) Ankylosing spondylitis Trial and failure of failed an adequate trial of at least two NSAIDs; OR use of NSAIDs is contraindicated in patient Enbrel (etanercept) Rheumatoid Arthritis (RA) Juvenile Idiopathic Arthritis (JIA) in members 2 years and older Psoriatic Arthritis (PsA) Ankylosing spondylitis Humira (adalimumab) Plaque Psoriasis (PsO) in patients 4 years or older Rheumatoid Arthritis (RA) Reducing signs and symptoms, inducing major clinical response, inhibiting the progression of structural damage, and improving physical function in adult patients with moderately to severely active RA. 2 P a g e
3 Juvenile Idiopathic Arthritis (JIA): Reducing signs and symptoms of moderately to severely active polyarticular JIA in patients 2 years of age and older. Psoriatic Arthritis (PsA): Reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in adult patients with active PsA. Ankylosing Spondylitis (AS): Reducing signs and symptoms in adult patients with active AS Adult Crohn s Disease (CD): Reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn s disease who have had an inadequate response to conventional therapy. Reducing signs and symptoms and inducing clinical remission in these patients if they have also lost response to or are intolerant to infliximab. Pediatric Crohn s Disease: Reducing signs and symptoms and inducing and maintaining clinical remission in patients 6 years of age and older with moderately to severely active Crohn s disease who have had an inadequate response to corticosteroids or immunomodulators such as azathioprine, 6- mercaptopurine, or methotrexate. Ulcerative Colitis (UC): Inducing and sustaining clinical remission in adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to immunosuppressants such as corticosteroids, azathioprine or 6-mercaptopurine (6-MP). The effectiveness of HUMIRA has not been established in patients who have lost response to or were intolerant to TNF blockers. Plaque Psoriasis (Ps): The treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. Hidradenitis Suppurativa (HS): The treatment of moderate to severe hidradenitis suppurativa. 3 P a g e
4 Uveitis (UV): The treatment of non-infectious intermediate, posterior and panuveitis in adult patients. Drug FDA Approved Indications Criteria for Approval Kineret (anakinra) Moderately to severely active RA hydroxychloroquine, minocycline) Cryopyrin-Associated Periodic Syndromes (CAPS) Approvable with confirmation of this diagnosis. Treatment of Neonatal-Onset Multisystem Inflammatory Disease Orencia (abatacept) Moderately to severely active RA hydroxychloroquine, minocycline) Juvenile Idiopathic Arthritis (JIA) in members 2 years and older Otezla (apremilast) Adult patients with active psoriatic arthritis Olumiant (baricitinib) Simponi (golimumab) Patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy Adult patients with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more tumor necrosis factor (TNF) antagonist therapies Moderately to severely active Rheumatoid Arthritis (RA) in adults, in combination with methotrexate Active Psoriatic Arthritis (PsA) in adults, alone or in combination with methotrexate Active Ankylosing Spondylitis in adults (AS) Must have a previous failure on a topical psoriasis agent and be a candidates for phototherapy or systemic therapy Patient age 18 years old; AND Use in combination with other JAK inhibitors, biologic disease-modifying antirheumatic drugs (DMARDs), or with potent immunosuppressants, such as azathioprine and cyclosporine, is not recommended methotrexate alone and at least one other DMARD (sulfasalazine, hydroxychloroquine, minocycline). Must be in combination with methotrexate. 4 P a g e
5 Moderately to severely active Ulcerative Colitis Trial and failure of a compliant regimen of oral or rectal aminosalicylates (i.e., sulfasalazine or mesalamine) for two consecutive months, AND Trial and failure of a compliant regimen of oral corticosteroids (for moderate to severe CD) unless contraindicated, or intravenous corticosteroids (for severe and fulminant CD or failure to respond to oral corticosteroids), AND Trial and failure of a compliant regimen of azathioprine or mercaptopurine for three consecutive months Drug FDA Approved Indications Criteria for Approval Xeljanz (tofacitinib) Xeljanz XR (tofacitinib) Cosentyx TM (secukinumab) Otrexup (methotrexate) Mod to severe active RA in adult members who are intolerant or not a candidate to methotrexate or in combination with methotrexate Adult Moderate to severe Plaque Psoriasis in adult patients who are candidates for systemic therapy or phototherapy. Adult patients with active psoriatic arthritis Adult patients with active ankylosing spondylitis Management of members with severe, active rheumatoid arthritis (RA) and polyarticular juvenile idiopathic arthritis (pjia), who are intolerant of or had an inadequate response to first-line therapy. Symptomatic control of severe, recalcitrant, disabling psoriasis in adults who are not adequately responsive to other forms of therapy. hydroxychloroquine, minocycline). Must have a previous failure on a topical psoriasis agent Length of Authorization: 6 months, then renew for 1 year for RA, if compliant and appropriate monitoring occurs. Approve for 6 months for psoriasis. Diagnosis of active rheumatoid arthritis (RA) Has had therapeutic failure to two preferred DMARD agents; AND Diagnosis of polyarticular juvenile idiopathic arthritis (pjia) Has had therapeutic failure to two preferred NSAIDS agents; AND 5 P a g e
6 Diagnosis of Psoriasis Rasuvo TM (methotrexate) Management of severe, active rheumatoid arthritis (RA) Polyarticular juvenile idiopathic arthritis (pjia), who are intolerant of or had an inadequate response to first-line therapy. Symptomatic control of severe, recalcitrant, disabling psoriasis in adults who are not adequately responsive to other forms of therapy. A therapeutic trial and failure on topical therapies such as topical emollients and/or topical corticosteroids, topical retinoids, topical vitamin D analogs, and topical tacrolimus AND pimecrolimus :AND Length of Authorization: 6 months, then renew for 1 year for RA, if compliant and appropriate monitoring occurs. Approve for 6 months for psoriasis. Diagnosis of active rheumatoid arthritis (RA) Has had therapeutic failure to two preferred DMARD agents; AND Diagnosis of polyarticular juvenile idiopathic arthritis (pjia) Has had therapeutic failure to two preferred NSAIDS agents; AND Diagnosis of Psoriasis A therapeutic trial and failure on topical therapies such as topical emollients and/or topical corticosteroids, topical retinoids, topical vitamin D analogs, and topical tacrolimus AND pimecrolimus :AND Quantity Limit = 4 auto-injectors per month For renewal, patient must be followed by a physician for monitoring of renal and hepatic function and complete blood counts with differential and platelet count. 6 P a g e
7 Taltz Adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. Routine PDL Patient has tried and failed at least 2 topical treatments, such as corticosteroids, calcipotriene, coal tar, tazarotene, or anthralin; 7 P a g e
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy
More informationINFLIXIMAB Remicade (infliximab), Inflectra (infliximab-dyyb), Ixifi* (infliximabqbtx), Renflexis (infliximab-abda)
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 6 years of age or older 1. Moderate to severe Crohn s disease (CD) a. Patient has fistulizing disease
More informationADALIMUMAB Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)
Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of moderate to severe rheumatoid
More informationPharmacy Management Drug Policy
SUBJECT: Inflammatory Conditions Clinical Review Prior Authorization (CRPA) Rx and Medical Drugs POLICY NUMBER: PHARMACY-73 EFFECTIVE DATE: 01/01/2018 LAST REVIEW DATE: 06/11/2018 If the member s subscriber
More informationBiologics for Autoimmune Diseases
Biologics for Autoimmune Diseases Goal(s): Restrict use of biologics to OHP funded conditions and according to OHP guidelines for use. Promote use that is consistent with national clinical practice guidelines
More informationFirst Name. Specialty: Fax. First Name DOB: Duration:
Prescriber Information Last ame: First ame DEA/PI: Specialty: Phone - - Fax - - Member Information Last ame: First ame Member ID umber DOB: - - Medication Information: Drug ame and Strength: Diagnosis:
More informationHARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES HUMIRA PEDIATRIC
Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 HUMIRA PEDIATRIC GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the patient currently taking Humira? If
More informationCosentyx. Cosentyx (secukinumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.11 Subject: Cosentyx Page: 1 of 7 Last Review Date: September 20, 2018 Cosentyx Description Cosentyx
More informationUnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2017 P 1041-8 Program Prior Authorization/Notification Medication Humira (adalimumab) P&T Approval Date 1/2007, 6/2008, 4/2009, 6/2009,
More informationCIMZIA (certolizumab pegol)
Pre - PA Allowance None Prior-Approval Requirements Age Diagnoses 18 years of age or older Patient must have ONE of the following: 1. Moderate to severe Crohn s Disease (CD) a. Inadequate response, intolerance
More information1. Does the patient have a diagnosis of moderate to severe polyarticular juvenile idiopathic arthritis (PJIA)?
Humira (adalimumab) Medication Request Form (MRF) for Healthy Indiana Plan (HIP) and Hoosier Healthwise (HHW) FAX TO: (858) 790-7100 c/o MedImpact Healthcare Systems, Inc. Attn: Prior Authorization Department
More informationStelara. Stelara (ustekinumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.04 Subject: Stelara Page: 1 of 9 Last Review Date: September 20, 2018 Stelara Description Stelara
More informationRegulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 9 Last Review Date: March 16, 2018 Simponi / Simponi
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell co-stimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Orencia Page: 1 of 9 Last Review Date: September 20, 2018 Orencia Description Orencia (abatacept)
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 8 Last Review Date: March 16, 2018 Orencia Description Orencia (abatacept)
More informationBiologic Immunomodulators Prior Authorization with Quantity Limit Program Summary
Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary Biologic Immunomodulators Prior Authorization with Quantity Limit (with a preferred option) OBJECTIVE The intent of the
More information2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N
12/21/2016 Prior Authorization Aetna Better Health of West Virginia Humira (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
More informationOtezla. Otezla (apremilast) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Otezla Page: 1 of 5 Last Review Date: March 16, 2018 Otezla Description Otezla (apremilast) Background
More informationRegulatory Status FDA-approved indications: Entyvio is an α4β7integrin receptor antagonist indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.12 Subject: Entyvio Page: 1 of 7 Last Review Date: September 20, 2018 Entyvio Description Entyvio
More informationC. Assess clinical response after the first three months of treatment.
Government Health Plan (GHP) of Puerto Rico Authorization Criteria Tumor Necrosis Factor Alpha (TNFα) Adalimumab (Humira ) Managed by MCO Section I. Prior Authorization Criteria A. Physician must submit
More informationHARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other CERTOLIZUMAB PEGOL CIMZIA 35554 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the request for a patient with a diagnosis of moderate
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationRegulatory Status FDA-approved indication: Humira and Amjevita are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 10 Last Review Date: June 22, 2017 Humira Description Humira (adalimumab),
More informationCimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.11 Section: Prescription Drugs Effective Date: April 1, 2018 Subject: Cimzia Page: 1 of 5 Last Review
More informationCircle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Otezla (apremilast) Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Otezla (apremilast) Prime Therapeutics will review Prior Authorization requests Prior
More informationRegulatory Status FDA-approved indication: Humira and Amjevita are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 13 Last Review Date: September 20, 2018 Humira Description Humira (adalimumab),
More information2. Is the patient responding to Remicade therapy? Y N
09/29/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Remicade (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationACTEMRA (tocilizumab)
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 1. Active Polyarticular Juvenile Idiopathic Arthritis (PJIA) b. Patient has an intolerance or has experienced
More informationRegulatory Status FDA-approved indication: Humira and Amjevita are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 14 Last Review Date: June 22, 2018 Humira Description Humira (adalimumab),
More information3. Did the patient show evidence of remission by week 8 of Humira Y N therapy?
09/23/2015 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationUnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2018 P 1017-7 Program Prior Authorization/Notification Medication Cimzia (certolizumab) P&T Approval Date 1/2007, 6/2008, 4/2009, 6/2009,
More informationHumira (adalimumab) DRUG.00002
Humira (adalimumab) DRUG.00002 Override(s) Prior Authorization Quantity Limit Approval Duration 1 year Medications Humira 10 mg/0.2 ml syringe Humira pediatric Crohn s Disease starter pack 40 mg/0.8 ml
More informationRegulatory Status FDA-approved indication: Humira and its biosimilars are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-5)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 13 Last Review Date: November 30, 2018 Humira Description Humira (adalimumab),
More informationInfliximab/Infliximab-dyyb DRUG.00002
Infliximab/Infliximab-dyyb DRUG.00002 Override(s) Prior Authorization Step Therapy Medications Remicade (infliximab) Inflectra (inflectra-dyyb) Approval Duration 1 year Comment Intravenous administration
More informationXeljanz. Xeljanz, Xeljanz XR (tofacitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.24 Subject: Xeljanz Page: 1 of 6 Last Review Date: March 16, 2018 Xeljanz Description Xeljanz, Xeljanz
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Biologic Immunomodulators Therapy Page 1 of 34 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Biologic Immunomodulators Therapy (Pharmacy Benefit Only) Prime Therapeutics
More informationAmjevita (adalimumab-atto)
*- Florida Healthy Kids Amjevita (adalimumab-atto) Override(s) Prior Authorization Quantity Limit Medications Amjevita 20 mg/0.4 ml prefilled syringe Amjevita (adalimumab-atto) 40 mg/0.8 ml 2 #* ^ prefilled
More informationHARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other GOLIMUMAB SIMPONI 22533, 22536, 34697, 35001 ROUTE = SUBCUTANE. GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the request for a
More informationImmune Modulating Drugs Prior Authorization Request Form
Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax:
More informationCyltezo (adalimumab-adbm) CG-DRUG-64, CG-DRUG-65
Market DC Cyltezo (adalimumab-adbm) CG-DRUG-64, CG-DRUG-65 Override(s) Prior Authorization Quantity Limit Medications Cyltezo (adalimumab-adbm) 40 mg/0.8 ml prefilled syringe #* ^ Approval Duration 1 year
More informationTherapeutic Agents in Rheumatic and Inflammatory Diseases Drug Class Prior Authorization Protocol
Therapeutic Agents in Rheumatic and Inflammatory Diseases Drug Class Prior Authorization Protocol Line of Business: Medi-Cal Effective Date: August 16, 2017 Revision Date: August 16, 2017 This policy has
More informationPharmacy Prior Authorization
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Humira (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationRemicade (infliximab) DRUG.00002
Applicability/Effective Date *- Florida Healthy Kids Remicade (infliximab) DRUG.00002 Override(s) Prior Authorization Step Therapy Medications Remicade (infliximab) Approval Duration 1 year Comment Intravenous
More informationETANERCEPT Generic Brand HICL GCN Exception/Other ETANERCEPT ENBREL GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)
Generic Brand HICL GCN Exception/Other ETANERCEPT ENBREL 18830 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of moderate to severe rheumatoid
More informationInflectra (infliximab-dyyb), Remicade (infliximab), Renflexis (infliximab-abda) DRUG CG-DRUG-64
Inflectra (infliximab-dyyb), Remicade (infliximab), Renflexis (infliximab-abda) DRUG.00002 CG-DRUG-64 Override(s) Prior Authorization *Washington Medicaid See State Specific Mandates Medications Inflectra
More informationRemicade (infliximab), Inflectra (infliximab-dyyb), Renflexis (infliximababda)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.02 Subject: Infliximab Page: 1 of 13 Last Review Date: December 8, 2017 Infliximab Description Remicade
More informationDRAFT. Therapeutic Class Code: D6A, S2J, S2M, S2Q, Z2U, Z2Z, S2Z, L1A, S2V, Z2V, D6K Therapeutic Class Description: Injectable Immunomodulators
AFT Therapeutic Class Code: D6A, S2J, S2M, S2Q, Z2U, Z2Z, S2Z, L1A, S2V, Z2V, D6K Therapeutic Class Description: Injectable Immunomodulators Medication Generic Code Number(s) NDC Number(s) Actemra SQ 35486
More informationMedication Policy Manual. Topic: Otezla, apremilast Date of Origin: May 9, 2014
Medication Policy Manual Policy No: dru342 Topic: Otezla, apremilast Date of Origin: May 9, 2014 Committee Approval Date: January 19, 2015 Next Review Date: January 2016 Effective Date: April 1, 2015 IMPORTANT
More informationRegulatory Status FDA-approved indication: Humira is a tumor necrosis factor (TNF) blocker indicated for the treatment of: (2)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.29 Subject: Humira Page: 1 of 9 Last Review Date: September 15, 2016 Humira Description Humira (adalimumab)
More informationRemicade. Remicade (infliximab), Inflectra (infliximab-dyyb) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.02 Subsection: Gastrointestinal nts Original Policy Date: May 20, 2011 Subject: Remicade Page: 1 of
More informationActemra. Actemra (tocilizumab) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.12 Subject: Actemra Page: 1 of 13 Last Review Date: September 20, 2018 Actemra Description Actemra
More informationRegulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of:
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 8 Last Review Date: March 17, 2017 Simponi / Simponi
More informationRegulatory Status FDA-approved indication: Orencia is a selective T cell costimulation modulator indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.18 Subject: Orencia Page: 1 of 6 Last Review Date: December 8, 2017 Orencia Description Orencia (abatacept)
More informationPharmacy Management Drug Policy
SUBJECT: Cimzia (Certolizumab pegol) - for Ankylosing Spondylitis, Crohn s Disease, Psoriatic Arthritis and Rheumatoid Arthritis POLICY NUMBER: PHARMACY-07 EFFECTIVE DATE: 5/2009 LAST REVIEW DATE: 6/13/2018
More informationDrugs and Applicable Coding: J-code: Enbrel-J1438; Humira-J0135; Remicade-J1745; Inflectra-Q5102; Cimzia-J0718; Simponi-J1602 Renflexis - pending
Policy Subject: Anti-TNF Agents Policy Number: SHS PBD16 Category: Rheumatology & Autoimmune Policy Type: Medical Pharmacy Department: Pharmacy Product (check all that apply): Group HMO/POS Individual
More informationSimponi / Simponi ARIA (golimumab)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 6 Last Review Date: September 15, 2016 Simponi / Simponi
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: golimumab_simponi 8/2013 2/2018 2/2019 3/2018 Description of Procedure or Service Golimumab (Simponi and
More informationInfusible Biologics Medical Policy Prior Authorization Program Summary
Infusible Biologics Medical Policy Prior Authorization Program Summary Precertification/Prior Authorization may be required under certain plans. Please verify each member s benefits. OBJECTIVE The intent
More informationRemicade. Remicade (infliximab), Inflectra (infliximab-dyyb) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Remicade Page: 1 of 9 Last Review Date: June 22, 2017 Remicade Description Remicade (infliximab),
More informationCorporate Medical Policy
Corporate Medical Policy Infliximab, Infliximab-dyyb, Infliximab-abda File Name: Origination: Last CAP Review: Next CAP Review: Last Review: infliximab 5/2002 2/2018 2/2019 7/2018 Description of Procedure
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: abatacept_orencia 4/2008 2/2018 2/2019 2/2018 Description of Procedure or Service Abatacept (Orencia ), a
More informationUnitedHealthcare Pharmacy Clinical Pharmacy Programs
UnitedHealthcare Pharmacy Clinical Pharmacy Programs Program Number 2018 P 1097-7 Program Prior Authorization/Notification Medication *Stelara (ustekinumab) *This program applies to the subcutaneous formulation
More informationCimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.11 Subject: Cimzia Page: 1 of 5 Last Review Date: December 8, 2017 Cimzia Description Cimzia (certolizumab
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Biologic Immunomodulators Therapy Page 1 of 26 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Biologic Immunomodulators Therapy (Pharmacy Benefit Only) Prime Therapeutics
More informationMedication Policy Manual. Topic: Xeljanz, tofacitinib Date of Origin: January 21, 2013
Medication Policy Manual Policy No: dru289 Topic: Xeljanz, tofacitinib Date of Origin: January 21, 2013 Committee Approval Date: January 19, 2015 Next Review Date: January 2016 Effective Date: April 1,
More informationRegulatory Status FDA-approved indication: Enbrel and Erelzi are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.27 Subject: Enbrel Page: 1 of 8 Last Review Date: March 16, 2018 Enbrel Description Enbrel (etanercept),
More informationSubject: Remicade (Page 1 of 5)
Subject: Remicade (Page 1 of 5) Objective: I. To ensure that Health Share/Tuality Health Alliance (THA) has a process by which the appropriate utilization of Remicade (Infliximab) for members whose diagnosis
More informationUnitedHealthcare Pharmacy Clinical Pharmacy Programs
Program Number 2017 P 3041-8 Program Step Therapy Medications UnitedHealthcare Pharmacy Clinical Pharmacy Programs *Orencia (abatacept) *This step criteria refers to the subcutaneous formulation of abatacept
More informationDrug Effectiveness Review Project Summary Report Biologics (Targeted Immune Modulators)
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationRegulatory Status FDA-approved indication: Enbrel and Erelzi are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.27 Subject: Enbrel Page: 1 of 10 Last Review Date: June 22, 2018 Enbrel Description Enbrel (etanercept),
More informationCimzia. Cimzia (certolizumab pegol) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Cimzia Page: 1 of 5 Last Review Date: March 17, 2017 Cimzia Description Cimzia (certolizumab pegol)
More informationDrug Therapy Guidelines
Simponi, Simponi Aria Applicable Medical Benefit x Effective: 2/13/18 Pharmacy- Formulary 1 x Next Review: 12/18 Pharmacy- Formulary 2 x Date of Origin: 7/2010 Pharmacy- Formulary 3/Exclusive x Review
More information2. Does the patient have a diagnosis of ulcerative colitis or Crohn s? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH LOUISIAA (MEDICAID) Remicade (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationPrior Authorization Conditions for Approval of Humira (adalimumab) Website Form Submit request via: Fax
Prior Authorization Conditions for Approval of Humira (adalimumab) Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Humira (adalimumab) require a prior
More informationCorporate Medical Policy
Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: infliximab_remicade 5/2002 2/2017 2/2018 2/2017 Description of Procedure or Service Infliximab (REMICADE
More informationMedical Policy An Independent Licensee of the Blue Cross and Blue Shield Association
Biologic Immunomodulators Therapy Page 1 of 28 Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association Title: See also: Biologic Immunomodulators Therapy (Pharmacy Benefit
More information3. Has the patient shown improvement in signs and symptoms of the disease? Y N
Pharmacy Prior Authorization MERC CARE (MEDICAID) Renflexis (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationXeljanz (tofacitinib), Xeljanz XR (tofacitinib extended-release)
Market DC Xeljanz (tofacitinib), Xeljanz XR (tofacitinib extended-release) Override(s) Prior Authorization Quantity Limit Medications Xeljanz (tofacitinib) Approval Duration 1 year Quantity Limit May be
More informationAmjevita (adalimumab-atto) CG-DRUG-64, CG-DRUG-65
Market DC Amjevita (adalimumab-atto) CG-DRUG-64, CG-DRUG-65 Override(s) Prior Authorization Quantity Limit Medications Amjevita 20 mg/0.4 ml prefilled syringe Amjevita (adalimumab-atto) 40 mg/0.8 ml 2
More informationWhat prescribers need to know
HUMIRA Citrate-free presentations in an Electronic Medical Record (EMR) What prescribers need to know 2 / This is your guide to identifying HUMIRA Citrate-free presentations in your Electronic Medical
More informationRHEUMATOID ARTHRITIS DRUGS
Rheumatology Biologics Criteria from the Exceptional Access Program RHEUMATOID ARTHRITIS DRUGS DRUG NAME BRS REIMBURSED DOSAGE FORM/ STRENGTH Adalimumab Humira 40 mg/0.8 syringe and 40mg/0.8 pen for Anakinra
More informationClinical Policy: Abatacept (Orencia) Reference Number: ERX.SPA.123 Effective Date:
Clinical Policy: (Orencia) Reference Number: ERX.SPA.123 Effective Date: 10.01.16 Last Review Date: 05.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationThis Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only.
This Coverage Policy applies to Individual Health Insurance Marketplace benefit plans only. Immunological Agents Biological Response Modifier-Tumor Necrosis Factor (TNF) Inhibitors: Enbrel (etanercept
More informationClinical Policy: Etanercept (Enbrel), Etanercept-szzs (Erelzi) Reference Number: ERX.SPA.07 Effective Date:
Clinical Policy: Etanercept (Enbrel), Etanercept-szzs (Erelzi) Reference Number: ERX.SPA.07 Effective Date: 10.01.16 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy
More informationPolicy Evaluation: Biologics for RA, Psoriasis, or Crohn s Disease
Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Infliximab (Remicade), Infliximab-dyyb (Inflectra), and Infliximab-abda (Renflexis) Reference Number: ERX.SPA.160 Effective Date: 10.01.16 Last Review Date: 05.18 Revision Log See Important
More informationDrug Class Review Targeted Immune Modulators
Drug Class Review Targeted Immune Modulators Final Update 5 Report June 2016 The purpose of reports is to make available information regarding the comparative clinical effectiveness and harms of different
More informationDrug Name (specify drug) Quantity Frequency Strength
Prior Authorization Form GEHA FEDERAL - STANDARD OPTION Autoimmune Conditions (FA-PA) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
More informationPolicy #: 061 Latest Review Date: October 2013
Name of Policy: TNF Antagonists and Other Biologics Policy #: 061 Latest Review Date: October 2013 Category: Pharmacy Policy Grade: A Background/Definitions: As a general rule, benefits are payable under
More informationClinical Policy: Etanercept (Enbrel) Reference Number: PA.CP.PHAR.250 Effective Date: 01/18 Last Review Date: 08/17 Line of Business: Medicaid
Clinical Policy: (Enbrel) Reference Number: PA.CP.PHAR.250 Effective Date: 01/18 Last Review Date: 08/17 Line of Business: Medicaid Coding Implications Revision Log Description (Enbrel ) is tumor necrosis
More information3. Does the patient have a diagnosis of rheumatoid arthritis (RA) with moderate to high disease activity?
Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Enbrel (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax
More informationClinical Policy: Ustekinumab (Stelara) Reference Number: ERX.SPMN.167
Clinical Policy: (Stelara) Reference Number: ERX.SPMN.167 Effective Date: 10/16 Last Review Date: 12/16 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory
More informationClinical Policy: Biologic DMARDs Reference Number: CP.CPA.194 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: Reference Number: CP.CPA.194 Effective Date: 01.01.18 Last Review Date: 12.17 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
More informationClinical Policy: Biologic DMARDs Reference Number: CP.CPA.194 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: Reference Number: CP.CPA.194 Effective Date: 01.01.18 Last Review Date: 05.18 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
More informationClinical Policy: Biologic DMARDs Reference Number: CP.CPA.194 Effective Date: Last Review Date: Line of Business: Commercial
Clinical Policy: Reference Number: CP.CPA.194 Effective Date: 01.01.18 Last Review Date: 02.19 Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory
More information