COVERED USES:

FDA-approved Indications:

1. Rheumatoid Arthritis - In adults with moderate to severely active disease.
2. Juvenile Idiopathic Arthritis - Reducing the signs and symptoms of moderately to severely active polyarticular juvenile idiopathic arthritis in patients 4 years of age and older.
3. Psoriatic Arthritis
4. Ankylosing Spondylitis
5. Crohn's Disease - Reducing signs and symptoms and inducing and maintaining clinical remission in adult patients with moderately to severely active Crohn's disease.
6. Chronic Plaque Psoriasis - Treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy.

All FDA-approved indications not otherwise excluded from Part D.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

For Rheumatoid Arthritis must be prescribed by (or in consultation with) a rheumatologist.

For Chronic Plaque Psoriasis must be prescribed by (or in consultation with) a rheumatologist or dermatologist.

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

For Rheumatoid Arthritis, the following criteria must be met:

• Documented trial and failure (6-12 weeks) of or contraindication to methotrexate and at least one of the following: sulfasalazine or leflunomide

For Chronic Plaque Psoriasis, the following criteria must be met:

• Documentation of involvement of at least 10% of BSA (unless on hands, face, or genetalia)
• Trial and failure of or contraindication to phototherapy or photochemotherapy
• Documented trial and failure of or contraindication to at least two conventional therapies including topical steroids, other topical agents (i.e. calcipotriene, tazarotene, and coal tar)

For Crohn's Disease, the following criteria must be met:

• Documented failure of at least two conventional therapies such as aminosalicylate, corticosteroids, immunomodulators or medical rationale why these cannot be tried.
• Patients with fistulizing Crohn's Disease do not need to fail conventional therapies first

For Psoriatic Arthritis, the following criteria must be met:

• Documented trial and failure (6-12 weeks) or contraindication to methotrexate, sulfasalazine, or NSAIDs.

For Ankylosing Spondylitis the following must be met:

• Documented trial and failure of or contraindication to one of the following: sulfasalazine, methotrexate, or NSAIDS

For all diagnoses, dosing must be consistent with labeling.

For reauthorization, documentation of adequate response to the medication must be provided.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization will be for up to six months. Reauthorization will be for up to one year.