Coverage is provided in the following conditions:
Patient is at least 18 years of age, unless otherwise specified; AND
Universal Criteria 1
Patient has been evaluated and screened for the presence of latent tuberculosis (TB) infection prior to initiating treatment and will receive ongoing monitoring for presence of TB during treatment; AND
Patient does not have an active infection, including clinically important localized infections; AND
Patient will not receive live vaccines during therapy; AND
Patient is not on concurrent treatment with another TNF inhibitor, biologic response modifier or other non-biologic agent (i.e., apremilast, tofacitinib, baricitinib); AND
Rheumatoid Arthritis (RA) 1-4,9-11,17
Must be prescribed by, or in consultation with, a specialist in rheumatology; AND
Documented moderate to severe active disease; AND
Patient has had at least a 3 month trial and failed of previous therapy with ONE oral disease modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.; AND
Prescribed in combination with methotrexate unless contraindicated
Psoriatic Arthritis (PsA) 5,6,8,18
Patient is at least 2 years of age; AND
Must be prescribed by, or in consultation with, a specialist in dermatology or rheumatology; AND
Documented moderate to severe active disease; AND
For patients with predominantly axial disease OR active enthesitis, a trial and failure of at least a 4 week trial of ONE non-steroidal anti-inflammatory agents (NSAIDs), unless use is contraindicated; OR
For patients with peripheral arthritis or dactylitis, a trial and failure of at least a 3 month trial of ONE oral disease-modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, sulfasalazine, or hydroxychloroquine
Ankylosing Spondylitis (AS) 7,12,19
Must be prescribed by, or in consultation with, a specialist in rheumatology; AND
Documented active disease; AND
Patient had an adequate trial and failure of at least TWO (2) non-steroidal anti-inflammatory agents (NSAIDs) over 4 weeks (in total), unless use is contraindicated
Polyarticular Juvenile Idiopathic Arthritis (pJIA) 14
Patient is at least 2 years of age; AND
Documented moderate to severe active polyarticular disease; AND
May be used alone or in combination with methotrexate; AND
Patient has had at least a 1-month trial and failure (unless contraindicated or intolerant) of previous therapy with either oral non-steroidal anti-inflammatory drugs (NSAIDs) OR an oral disease-modifying anti-rheumatic agent (DMARD) (e.g., methotrexate, leflunomide, sulfasalazine, etc.)
