COVERED USES:

Humira® is covered for the following uses:

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

Requests for a non-FDA approved ("off-label") indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

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 additional criteria must be met:

• Documented failure (6-12 weeks) of at least 2 other DMARDs including methotrexate or medical rationale why these cannot be tried.

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

• Documented failure of at least two conventional therapies including topical steroids or other topical agents such as calcipotriene, tazarotene, and coal tar or medical rationale why these cannot be tried.

For Crohn's Disease the following additional 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

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.