Medication Policy Manual. Topic: Otezla, apremilast Date of Origin: May 9, 2014
|
|
- Cory May
- 6 years ago
- Views:
Transcription
1 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 REMINDER This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status. Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care. Description Apremilast (Otezla) is an oral medication that inhibits phosphodiesterase-4 (PDE4), a protein present in immune cells that is associated with inflammation. It is used to treat chronic plaque psoriasis and psoriatic arthritis. dru342.1 Page 1 of 13
2 Policy/Criteria I. Most contracts require prior authorization approval of apremilast (Otezla) prior to coverage. Apremilast (Otezla) may be considered medically necessary when at least one of the criteria, A or B below, is met. A. A diagnosis of chronic plaque psoriasis (PsO) when established by or in consultation with a specialist in dermatology or rheumatology and all of criteria 1 through 4 below are met. OR 1. Clinical documentation supports involvement of at least 10% of the body surface area or there is significant functional disability. AND 2. Treatment with phototherapy (for example, UVB) or photochemotherapy was not effective, not tolerated, or is contraindicated (see Appendix 1). AND 3. Treatment with at least one oral DMARD (such as methotrexate) was not effective or not tolerated, unless all are contraindicated (see Appendix 2). AND 4. There is clinical documentation that treatment with three preferred biologic therapies were each not effective after at least a 12-week treatment course unless each were not tolerated or were contraindicated (see Appendix 3). B. A diagnosis of psoriatic arthritis (PsA) and both criteria 1 and 2 below are met. 1. Diagnosis is established by or in consultation with a specialist in dermatology or rheumatology. AND 2. There is clinical documentation that treatment with three preferred biologic therapies were each not effective after at least a 12-week treatment course unless each were not tolerated or were contraindicated (see Appendix 3). II. Administration, Quantity Limitations, and Authorization Period A. OmedaRx considers apremilast (Otezla) to be a self-administered medication. B. When prior authorization is approved, apremilast (Otezla) may be authorized in quantities of 60 tablets per 30 days. C. Authorization may be reviewed at least annually to confirm that current medical necessity criteria are met and that the medication is effective. dru342.1 Page 2 of 13
3 III. Apremilast (Otezla) is considered investigational when used for all other conditions, including but not limited to: A. Use in combination with a biologic response modifier (see Appendix 3), or tofacitinib (Xeljanz) B. Acne C. Ankylosing spondylitis (AS) D. Atopic dermatitis/contact dermatitis E. Behçet s disease F. Chronic pelvic pain syndrome G. Chronic prostatitis H. Cutaneous lupus I. Dermatomyositis J. Gouty arthritis K. Lichen planus L. Osteoarthritis M. Rheumatoid arthritis N. Rosacea O. Uveitis Position Statement - There are many treatments for chronic inflammatory conditions that are effective, have known long-term safety profiles, and are recommended by national treatment guidelines. - Non-medical therapies, such as prescribed exercise therapy, physical therapy, weight loss, and smoking cessation are important treatment plan components for patients suffering from many chronic inflammatory conditions. - When a systemic medication therapy is needed to manage a chronic inflammatory condition, generic oral therapies usually offer the best value. - When non-medical therapies and oral medications are inadequate, a biologic medication may be appropriate. - Preferred/formulary biologic medications for the treatment of chronic inflammatory conditions include: adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab IV (Simponi Aria) and ustekinumab (Stelara). - No studies have shown that any one biologic medication is more effective than another in the treatment of chronic inflammatory conditions; however, the data for some individual products is of sufficient quality that indirect comparison can be made. * Indirect comparison is made base on the calculated number needed to treat (NNT) which describes the average number of patients that need to be treated for one patient to benefit. * The lower the NNT, the more likely the medication will have a benefit. * Products with similar NNTs can be considered to have comparable efficacy. dru342.1 Page 3 of 13
4 - When there is no demonstrated difference in safety or efficacy, the medication with the lowest cost often provides the best value for members. - Individual responses and tolerability of biologics are unpredictable and may vary between patients. If one biologic agent provides an inadequate response, another biologic may yet be effective. - Due to the potential for development of antibodies with anti-tnf therapies (see Table 1), which may result in loss of efficacy, clinical practice guidelines generally recommend a trial with no more than two anti-tnf therapies. [1] For those who have an inadequate response or intolerance to two anti-tnf therapies, it is reasonable to consider a biologic with an alternative mechanism of action and proven efficacy for the patient s diagnosis [e.g. abatacept (Orencia), tocilizumab (Actemra), rituximab (Rituxan), or ustekinumab (Stelara)]. - All biologics (both anti-tnfs and non-anti-tnfs) carry a risk of severe infections. There is no conclusive evidence that any one biologic option has a superior safety profile. - There is significant variation in recommended dosing across indications for individual medications; therefore, when multiple dosage forms of a biologic agent are available, coverage can be provided for those indications where the dosage form has been evaluated in randomized controlled trials, the dosage form has been proven safe and effective, and for which the dosage form has an established dose. For all other indications, the specific dosage form will be considered investigational. Clinical Efficacy Rheumatic Conditions Background - Treatments for rheumatic conditions may include non-medical therapies, medications for the management of symptoms, medications that modify the disease course such as oral or biologic disease modifying anti-rheumatic drugs (DMARD), including the first-in-class phosphodiesterase 4 (PDE4) inhibitor apremilast (Otezla) and the Janus kinase (JAK) inhibitor, tofacitinib (Xeljanz). - Medications to control inflammation such as nonsteroidal antiinflammatory medications (e.g. ibuprofen, indomethacin, and naproxen) and glucocorticoids (oral or injected into the joint) are effective for the management of symptoms, particularly during the early stages of disease. - Generic, orally administered DMARDs, including methotrexate (MTX), hydroxychloroquine, leflunomide, and sulfasalazine are effective for decreasing symptoms and slowing disease progression, have a proven track record, and have been the standard of care for many years. * MTX is considered effective in the treatment of rheumatoid arthritis (RA) and is the standard reference DMARD to which newer oral and biologic DMARDs are compared for efficacy. * Generic oral therapies have known potential risks. The management of these risks is well established. - The biologic agents can also decrease symptoms, help preserve joint functioning, and slow the progression of chronic inflammatory conditions; however, these medications also have significant risks. dru342.1 Page 4 of 13
5 - There is no comparative safety data within the biologics class that indicates one medication or mechanism of action is safer than alternatives, including anti-tnfs compared to non-anti- TNF medications. - In RA, the best response is seen when MTX is used concomitantly with any of the biologics. Infliximab (Remicade) and golimumab (Simponi, Simponi Aria) have been shown to be effective only when used with MTX. Treatment options other than infliximab (Remicade) or golimumab (Simponi, Simponi Aria) should be considered for patients who cannot take MTX. - Inhibiting PDE4 is a novel mechanism in the treatment of rheumatic conditions. PDE4 is a protein present in immune cells and is associated with inflammation. - JAK inhibition is a novel mechanism in the treatment of rheumatic conditions. JAKs are enzymes that stimulate hematopoiesis and promote immune cell function. Rheumatic Conditions Psoriatic Arthritis (PsA) - Several biologic agents have been shown to be effective in the treatment of PsA including the following: * Adalimumab (Humira) * Certolizumab pegol (Cimzia) * Etanercept (Enbrel) * Golimumab (Simponi) * Infliximab (Remicade) * Ustekinumab (Stelara) - All of these agents, with the exception of certolizumab pegol (Cimzia), have high quality data in the treatment of PsA (see Table 1) and, therefore, can be indirectly compared based on their calculated NNTs (see Table 2). - With the exception of certolizumab pegol (Cimzia), the efficacy of these agents in the treatment of PsA is similar. - Currently, the efficacy of apremilast (Otezla) relative to biologic DMARDs in the treatment of PsA is unknown. dru342.1 Page 5 of 13
6 Efficacy of apremilast (Otezla) in psoriatic arthritis (PsA) - The efficacy of apremilast (Otezla) in the treatment of PsA was evaluated in three randomized, placebo-controlled trials in a total of 1,493 patients with active PsA despite treatment with an oral DMARD. Previous treatment with up to one biologic medication was also permitted. Patients were allowed to remain on stable doses of oral DMARDs, low dose corticosteroids, or nonsteroidal antiinflammatory medications for the duration of the trials. [2] - The primary endpoint assessed was the proportion of patients who achieved a 20% improvement in the American College of Rheumatology criteria (ACR20) at 16 weeks. - In all three studies, the proportion of patients who achieved ACR20 was statistically significantly greater with apremilast (Otezla) than with placebo (32% to 41% vs 18% to 19%, respectively). [2] Skin Conditions Chronic Plaque Psoriasis (PsO) - Several biologic agents have been shown to be effective in the treatment of PsO including the following: * Adalimumab (Humira) * Etanercept (Enbrel) * Infliximab (Remicade) * Ustekinumab (Stelara) - All of these agents have high quality data in the treatment of PsO (see Table 1) and, therefore, can be indirectly compared based on their calculated NNTs (see Table 2). - The efficacy of these agents in the treatment of PsO is similar. - Currently, the efficacy of apremilast (Otezla) relative to biologic DMARDs in the treatment of PsO is unknown. Efficacy of apremilast (Otezla) in chronic plaque psoriasis (PsO) - The efficacy of apremilast (Otezla) in the treatment of PsO was evaluated in two, unpublished, randomized, placebo-controlled trials in a total of 1,257 subjects with moderate to severe plaque psoriasis [body surface area (BSA) involvement of 10%, static Physician Global Assessment (spga) of 3, Psoriasis Area and Severity Index (PASI) score 12, candidates for phototherapy or systemic therapy]. Patients were allowed to use low-potency topical corticosteroids on the face, axilla and groin. Patients with scalp psoriasis were allowed to use coal tar shampoo and/or salicylic acid scalp preparations on scalp lesions. [2] - The primary endpoint assessed was the proportion of patients who achieved a 75% improvement in the Psoriasis Area and Severity Index (PASI-75) at 16 weeks. [2] - In each study, the proportion of patients who achieved PASI-75 was statistically significantly greater with apremilast (Otezla) than with placebo (29% to 33% vs 5% to 6%, respectively). [2] dru342.1 Page 6 of 13
7 Other Conditions Apremilast (Otezla) has been studied in a variety of other conditions. Due to lack of published data, lack of high quality data, or lack of positive data these conditions are considered investigational. Details of select investigational uses are reported below. Ankylosing spondylitis (AS) - One double-blind, placebo-controlled, single-center, pilot study evaluated the efficacy of apremilast (Otezla) in patients with AS. The primary endpoint in this study, change in Bath Ankylosing Spondylitis Disease Activity Index at week 12, was not met. [3] Behçet s disease - Apremilast (Otezla) is currently approved for Behçet s disease in Europe; however, there is no published data evaluating the efficacy of apremilast (Otezla) in patients in the U.S. [4] Safety Summary - All biologic and non-biologic DMARDs have an adequate track record of clinical experience ( 3 years) with the exception of tofacitinib (Xeljanz), vedolizumab (Entyvio) and golimumab (Simponi Aria); however, the compound golimumab has been available as Simponi since All biologics (both anti-tnfs and non-anti-tnfs) carry a risk of severe infections. There is no conclusive evidence that any one biologic option has a superior safety profile. - Apremilast (Otezla) has a short track record of clinical experience (< 1 year) in the U.S. for the treatment of PsA. It has been approved in Europe for the treatment of Behçet s disease since August Immune suppression and subsequent increased risk of infection or malignancy is a potential risk with all biologic and non-biologic DMARDs. Serious infections such as tuberculosis and fungal infections should be considered prior to starting any of these therapies. - Branded DMARDs are not recommended to be given concomitantly, should be used with caution when given concomitantly with other immunosuppressive therapies, and may interfere with live vaccines. Safety of apremilast (Otezla) - The most common ( 5%) adverse events reported in clinical trials with apremilast (Otezla) were diarrhea, nausea, and headache. - Significant warnings include worsening of depression or suicidal thoughts, excessive weight loss, and drug interactions which may result in loss of efficacy. - Other medications used in the treatment of PsA have varying safety profiles; however, all suppress the immune system and are, therefore, associated with an increased risk of infection and malignancy. Apremilast (Otezla) is not associated with this risk. dru342.1 Page 7 of 13
8 Tables and Appendices Table 1. Summary of Evidence Quality by Indication for Select Disease Modifying Anti- Rheumatic Drugs (DMARD) Generic (brand) [Original FDA-approval Date] Route/Site of Administration Mechanism of action Rheumatoid Arthritis Psoriatic Arthritis Ankylosing Spondylitis Juvenile Idiopathic Arthritis Systemic Juvenile Idiopathic Arthritis Chronic Plaque Psoriasis Crohn s Disease Ulcerative Colitis infliximab (Remicade) [8/1998] etanercept (Enbrel) [11/1998] adalimumab (Humira) [12/2002] certolizumab pegol (Cimzia) [4/2008] golimumab (Simponi) [4/2009] golimumab (Simponi Aria) [7/2013] rituximab (Rituxan) [11/1997] anakinra (Kineret) [11/2001] canakinumab (Ilaris) [6/2009] tocilizumab (Actemra) [1/2010] tocilizumab (Actemra) [10/2013] ustekinumab (Stelara) [9/2009] natalizumab (Tysabri) [11/2004] vedolizumab (Entyvio) [5/2014] IV/HCP IV/HCP IV/HCP IV/HCP, HCP TNF antagonist (anti- TNF) TNF antagonist (anti- TNF) TNF antagonist (anti- TNF) TNF antagonist (anti- TNF) TNF antagonist (anti- TNF) B-lymphocyte depleter IL-1 receptor antagonist IL-1β receptor antagonist IL-6 receptor antagonist IL-12, -23 receptor antagonist a x x x a a x x x x x x x IV/HCP Integrin inhibitor x IV/HCP Integrin inhibitor x x x abatacept (Orencia) [12/2005] abatacept (Orencia) [12/2011] IV/HCP T-lymphocyte inhibitor x tofacitinib (Xeljanz) [11/2012] PO/Pat JAK inhibitor x apremilast (Otezla) [3/2014] PO/Pat PDE-4 inhibitor b HCP = healthcare provider administered; IL = interleukin; IV = intravenous; JAK = Janus kinases; Pat = patient (self) administered; PDE = phosphodiesterase; PO = oral; SC = subcutaneous; TNF = tumor necrosis factor; = FDAapproved indication and high confidence data; x = FDA-approved indication and less than high confidence data; = not FDA-approved, but specifically recommended by clinical practice guidelines a Refers to data for induction therapy only. Data for maintenance therapy is less than high confidence. b =FDA approved, but evidence has not undergone complete appraisal dru342.1 Page 8 of 13
9 Table 2. Summary of Likelihood of Symptom Improvement with Select Disease Modifying Anti-Rheumatic Drugs (DMARDs) a Condition Description of symptom improvement Medication abatacept (Orencia) adalimumab (Humira) anakinra (Kineret) apremilast (Otezla) certolizumab pegol (Cimzia) etanercept (Enbrel) golimumab (Simponi) infliximab (Remicade) natalizumab (Tysabri) rituximab (Rituxan) tocilizumab (Actemra) tofacitinib (Xeljanz) ustekinumab (Stelara) vedolizumab (Entyvio) Ankylosing Spondylitis At least a 20% improveme nt in ASAS (Range 3-4) Psoriatic Arthritis At least a 20% improveme nt in ACR criteria Rheumatoid Arthritis At least a 20% improveme nt in ACR criteria (Range 3-4) Chronic Plaque Psoriasis At least a 75% improveme nt in PASI Crohn s Disease Remission based on the CDAI Ulcerative Colitis Remission based on the Mayo score Initial NNT = 7 (Range 5-8) Ongoing Initial NNT = 11 Ongoing NNT = 7 (Range 3-4) NNT = 6 (Range 4-8) (Range 3-4) (Range 3-5) at this time at this time Initial Ongoing Initial Ongoing (Range 3-5) (Range 4-5) Initial Ongoing Initial Ongoing ACR = American College of Rheumatology; ASAS = Assessment in Ankylosing Spondylitis International Working Group Criteria; PASI = Psoriasis Area Severity Index a In select conditions. Likelihood of symptom improvement relative to placebo after three to six months of treatment based on number needed to treat (NNT). An NNT represents the average number of patients that need to be treated for one patient to benefit and can be calculated only where there is high confidence data. dru342.1 Page 9 of 13
10 Appendix 1: Absolute and Relative Contraindications for Phototherapy/Photochemotherapy - Type 1 or type 2 skin - History of photosensitivity - Increased risk of photosensitivity due to concomitant disease state (e.g. porphyria, systemic lupus erythematosus) or chronic medication use (e.g. tetracycline or sulfonamide antibiotics) - Treatment of facial or scalp lesions - Treatment of lesions in the groin area - Treatment of lesions on the palms of the hands or soles of the feet, or on nail beds - Presence of premalignant lesions (e.g. actinic keratosis) - History of melanoma or squamous-cell carcinoma - Physical inability to stand for the required exposure time Appendix 2: Select List of Oral Disease Modifying Anti-rheumatic Drugs (DMARD) Oral DMARDS for Rheumatic and Skin Conditions azathioprine (Imuran) methotrexate (oral, injectable) cyclosporine (Gengraf, Neoral, Sandimmune) mycophenolate (CellCept, Myfortic) hydroxychloroquine (Plaquenil) sulfasalazine (Azulfidine) leflunomide (Arava) dru342.1 Page 10 of 13
11 Appendix 3: Select Biologic Response Modifiers - Actemra, tocilizumab - Cimzia, certolizumab pegol - Enbrel, etanercept* - Entyvio, vedolizumab - Humira, adalimumab* - Kineret, anakinra - Orencia, abatacept - Remicade, infliximab* - Rituxan, rituximab - Simponi, golimumab - Stelara, ustekinumab* - Tysabri, natalizumab * Preferred/formulary medications for dermatology-related conditions Cross References Actemra, tocilizumab dru209 Cimzia, certolizumab dru160 Enbrel, etanercept dru035 Entyvio, vedolizumab dru356 Humira, adalimumab dru081 Kineret, anakinra dru049 Orencia, abatacept dru129 Rituxan, rituximab dru214 Simponi, golimumab dru183 Tysabri, natalizumab dru111 Xeljanz, tofacitinib dru289 dru342.1 Page 11 of 13
12 Codes Number Description CPT Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) (Use in conjunction with 96365, 96367) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) (Use in conjunction with 96365, 96374, 96409, if provided as a secondary or subsequent service after a different initial service is administered through the same IV access. Report only once per sequential infusion of same infusate mix) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) (Use in conjunction with 96365, 96366, 96413, 96415, Report only once per encounter) HCPCS J0129 Injection, abatacept, 10 mg, for intravenous use J0135 J0717 J1438 J1602 J1745 J2323 J3262 J3357 J9310 Injection, adalimumab, 20 mg (to be used only when drug is given under direct supervision of a physician) Injection, certolizumab pegol, 1 mg (to be used only when drug is given under direct supervision of a physician) Injection, etanercept, 25 mg and 50 mg (to be used only when drug is given under direct supervision of a physician) Injection, golimumab, 1 mg, for intravenous use Injection, infliximab, 10 mg Injection, natalizumab, 1 mg Injection, tocilizumab, 1 mg, for intravenous use Injection, ustekinumab, 1 mg Injection, rituximab, 100 mg dru342.1 Page 12 of 13
13 References 1. European League Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. [cited 09/13/2013]; Available from: 2. Otezla [package insert]. Summit, NJ: Celgene Corporation; 03/ Pathan, E, Abraham, S, Van Rossen, E, et al. Efficacy and safety of apremilast, an oral phosphodiesterase 4 inhibitor, in ankylosing spondylitis. England, p European Medicines Agency (EMA) [internet database]. London, United Kingdom: European Union; Updated daily dru342.1 Page 13 of 13
Medication 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 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 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 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 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 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 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 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 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 informationDrug 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 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 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 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 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 informationCommittee Approval Date: February 17, 2015 Next Review Date: January 2016
Medication Policy Manual Policy No: dru209 Topic: Actemra, tocilizumab Date of Origin: March 12, 2010 Committee Approval Date: February 17, 2015 Next Review Date: January 2016 Effective Date: May 1, 2015
More information1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
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
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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 informationCigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Apremilast Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 4 Effective Date... 1/1/2018 Next
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 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 informationCenter for Evidence-based Policy
P&T Committee Brief Targeted Immune Modulators: Comparative Drug Class Review Alison Little, MD Center for Evidence-based Policy Oregon Health & Science University 3455 SW US Veterans Hospital Road, SN-4N
More informationCIMZIA (certolizumab pegol)
CIMZIA (certolizumab pegol) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices
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 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 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 informationcertolizumab pegol (Cimzia )
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
More information(tofacitinib) are met.
Xeljanz (tofacitinib) Policy Number: 5.01. 560 Origination: 3/2014 Last Review: 3/2014 Next Review: 3/2015 Policy BCBSKC will provide coverage for Xeljanz (tofacitinib) when it is determined to be medically
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 informationClinical Policy: Ustekinumab (Stelara) Reference Number: ERX.SPA.01 Effective Date:
Clinical Policy: (Stelara) Reference Number: ERX.SPA.01 Effective Date: 04.01.17 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
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 informationClinical Policy: Apremilast (Otezla) Reference Number: CP.PHAR.245 Effective Date: Last Review Date: Line of Business: HIM, Medicaid
Clinical Policy: (Otezla) Reference Number: CP.PHAR.245 Effective Date: 08.16 Last Review Date: 11.18 Line of Business: HIM, Medicaid Revision Log See Important Reminder at the end of this policy for important
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 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 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 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 informationClinical Policy: Tofacitinib (Xeljanz, Xeljanz XR) Reference Number: ERX.SPA.110 Effective Date:
Clinical Policy: Tofacitinib (Xeljanz, Xeljanz XR) Reference Number: ERX.SPA.110 Effective Date: 10.01.16 Last Review Date: 05.18 Revision Log See Important Reminder at the end of this policy for important
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 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 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 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 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 information2017 Blue Cross and Blue Shield of Louisiana
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
More informationORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
UnitedHealthcare Community Plan Medical Benefit Drug Policy ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION Policy Number: CS2018D0039J Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
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 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 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 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 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 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 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 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 informationCOSENTYX (secukinumab)
COSENTYX (secukinumab) Non-Discrimination Statement and Multi-Language Interpreter Services information are located at the end of this document. Coverage for services, procedures, medical devices and drugs
More informationustekinumab (Stelara )
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
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 6 Last Review Date: December 8, 2017 Stelara Description Stelara (ustekinumab)
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 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 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 informationClinical Policy: Anakinra (Kineret) Reference Number: ERX.SPA.135 Effective Date:
Clinical Policy: (Kineret) Reference Number: ERX.SPA.135 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 informationClinical Policy: Baricitinib (Olumiant) Reference Number: CP.PHAR.135 Effective Date: Last Review Date: 11.18
Clinical Policy: (Olumiant) Reference Number: CP.PHAR.135 Effective Date: 07.24.18 Last Review Date: 11.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
More informationFml Limits. Azathioprine (Imuran) 50mg, 75mg, 100mg - $26.85 Cyclosporine, 25mg, 100mg. $ Leflunomide (Arava) 10mg Tablet - $144.
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Rheumatoid Arthritis (RA) P&T DATE: 2/15/2017 CLASS: Rheumatology/Anti-inflammatory Disorders REVIEW HISTORY 2/16, 5/15,
More informationClinical Policy: Secukinumab (Cosentyx) Reference Number: CP.PHAR.261 Effective Date: 08/16 Last Review Date: 08/17
Clinical Policy: (Cosentyx) Reference Number: CP.PHAR.261 Effective Date: 08/16 Last Review Date: 08/17 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
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 informationClinical Policy: Secukinumab (Cosentyx) Reference Number: CP.PHAR.261 Effective Date: Last Review Date: Line of Business: HIM, Medicaid
Clinical Policy: (Cosentyx) Reference Number: CP.PHAR.261 Effective Date: 08.16 Last Review Date: 11.18 Line of Business: HIM, Medicaid Coding Implications Revision Log See Important Reminder at the end
More informationORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION
ORENCIA (ABATACEPT) INJECTION FOR INTRAVENOUS INFUSION UnitedHealthcare Commercial Medical Benefit Drug Policy Policy Number: 2018D0039J Effective Date: March 1, 2018 Table of Contents Page INSTRUCTIONS
More informationPsoriatic Arthritis- Secondary Care
Psoriatic Arthritis- Secondary Care Our Psoriatic Arthritis: First Line Treatments information sheet gives information on the treatments that can be prescribed by a GP, or that might be prescribed if the
More informationCoverage Criteria: Express Scripts, Inc. monograph dated 12/15/ months or as otherwise noted by indication
BENEFIT DESCRIPTION AND LIMITATIONS OF COVERAGE ITEM: PRODUCT LINES: COVERED UNDER: DESCRIPTION: CPT/HCPCS Code: Company Supplying: Setting: Kineret (anakinra subcutaneous injection) Commercial HMO/PPO/CDHP
More information2017 Blue Cross and Blue Shield of Louisiana
Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided
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 informationPsoriatic Arthritis- Second Line Treatments
Psoriatic Arthritis- Second Line Treatments Second line treatments for Psoriatic Arthritis (PsA) are usually prescribed by a Rheumatologist, Dermatologist, or in a combined clinic where both the Dermatologist
More informationMedical Coverage Guidelines are subject to change as new information becomes available.
ENBREL (etanercept) Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline
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 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 informationClinical Policy: Apremilast (Otezla) Reference Number: CP.PHAR.245 Effective Date: 08/16 Last Review Date 08/17
Clinical Policy: (Otezla) Reference Number: CP.PHAR.245 Effective Date: 08/16 Last Review Date 08/17 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important
More informationClinical Policy: Secukinumab (Cosentyx) Reference Number: ERX.SPA.165 Effective Date:
Clinical Policy: (Cosentyx) Reference Number: ERX.SPA.165 Effective Date: 10.01.16 Last Review Date: 11.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
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 5 Last Review Date: March 17, 2017 Xeljanz Description Xeljanz, Xeljanz
More informationDrug Class Review Targeted Immune Modulators
Drug Class Review Targeted Immune Modulators Final Update 3 Report March 2012 The Agency for Healthcare Research and Quality has not yet seen or approved this report The purpose of the is to summarize
More informationClinical Policy: Secukinumab (Cosentyx) Reference Number: ERX.SPA.165 Effective Date:
Clinical Policy: (Cosentyx) Reference Number: ERX.SPA.165 Effective Date: 10.01.16 Last Review Date: 11.17 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More information1. Background: Infliximab is administered parenterally; therefore, it is not covered under retail pharmacy benefits.
Subject: Infliximab (Remicade ) Original Original Committee Approval: October 13, 2006 Revised Last Committee Approval: December 3, 2008 Last Review: October 19, 2007 1. Background: Infliximab is a genetically
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 information