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Prior Authorization Protocol
ACTEMRA (tocilizumab), CIMZIA (certolizumab pegol), COSENTYX (secukinumab), ENBREL (etanercept), ENTYVIO (vedolizumab), HUMIRA (adalimumab), INFLECTRA (infliximab-dyyb), KINERET (anakinra), ORENCIA (abatacept), OTEZLA (apremilast), REMICADE (infliximab), SIMPONI, SIMPONI ARIA (golimumab), STELARA (ustekinumab), TALTZ (ixekizumab), TYSABRI (natalizumab), XELJANZ, XELJANZ XR (tofacitinib)


HNMC

Interim Guidelines; Final Review and Approval by the P&T Committee Pending

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.
  1. FDA Approved Indications:

    AS
    CD
    UC
    NOMID
    pJIA
    sJIA
    PP
    PsA
    RA
    HS
    MS
    UV
    Actemra
    x (IV)
    x (IV)
    x
    Cimzia
    x
    x
    x
    x
    Cosentyx
    x
    x
    x
    Enbrel
    x
    x
    x
    x
    x
    Entyvio
    x
    x
    Humira
    x
    x
    x
    x
    x
    x
    x
    x
    x
    Inflectra
    x
    x
    x
    x
    x
    x
    Kineret
    x
    x
    Orencia
    x (IV)
    x
    Otezla
    x
    x
    Remicade
    x
    x
    x
    x
    x
    x
    Simponi
    x
    x
    x
    x
    Simponi Aria
    x
    Stelara
    x
    x
    x
    Tysabri
    x
    x
    Xeljanz/
    Xeljanz XR
    x

    AS=ankylosing spondylitis; CD=Crohns disease; UC=ulcerative colitis; NOMID=neonatal-onset multisystem inflammatory disease; pJIA=polyarticular juvenile idiopathic arthritis; sJIA=systemic juvenile idiopathic arthritis; PP=plaque psoriasis; PsA= psoriatic arthritis; RA=rheumatoid arthritis; HS=Hidradenitis Suppurativa, UV= uveitis
  2. Health Net Approved Indications and Usage Guidelines:

    Rheumatoid Arthritis [for Actemra, Cimzia, Enbrel, Humira, Inflectra, Kineret, Orencia, Remicade, Simponi, Simponi Aria, Xeljanz, Xeljanz XR]

    • Diagnosis of rheumatoid arthritis (RA)
    AND
    • Confirmed by a Rheumatologist
    OR
    • Defined at baseline prior to disease modifying anti-rheumatic drug (DMARD) treatment initiation by the (American College of Rheumatology (ACR)) criteria (refer to General Information for ACR criteria)
    AND
    • Failure or clinically significant adverse effects to methotrexate (MTX) in the last year for patients who are new to biologics
    OR
    • If patient is not a candidate for MTX (i.e., patient is a smoker [increased risk of MTX lung disease] or MTX is contraindicated), then failure or clinically significant adverse effect to sulfasalazine or 1 other DMARD
    AND [for Kineret only]
    • Failure or clinically significant adverse effects to a 3-month minimum trial of a tumor necrosis factor (TNF) blocking agent (e.g., EnbrelR, HumiraR, RemicadeR, CimziaR, SimponiR)

    AND [for intravenous Actemra, Orencia, Inflectra]

    • Failure or clinically significant adverse effects to a trial of Remicade, unless contraindicated.

    Psoriatic Arthritis [for Cimzia, Cosentyx, Enbrel, Humira, Otezla, Remicade, Simponi, Stelara]

    • Diagnosis of active Psoriatic Arthritis
    AND
    • Confirmed by a Rheumatologist or Dermatologist
    AND
    • Failure or clinically significant adverse effects to MTX unless contraindicated

    Ankylosing Spondylitis [for Cimzia, Cosentyx, Enbrel, Humira, Inflectra, Remicade, Simponi]

    • Diagnosis of active Ankylosing Spondylitis
    AND
    • Failure or clinically significant adverse effects to at least two NSAIDs for at least 1 month at maximal recommended or tolerated anti-inflammatory dose, unless contraindicated

    Crohns Disease [for Cimzia, Entyvio, Humira, Inflectra, Remicade, Stelara, Tysabri]

    • Diagnosis of moderate to severe Crohn's Disease
    AND
    • Confirmed by a gastroenterologist
    AND [for Cimzia, Entyvio, Tysabri, Inflectra]
    • Failure or clinically significant adverse effects to HumiraR or RemicadeR or Stelara

    Ulcerative Colitis [for Entyvio, Humira, Inflectra, Remicade, Simponi]

    • Diagnosis of moderate to severe ulcerative colitis
    AND
    • Confirmed by a gastroenterologist
    AND
    For Induction:
    • Patient is not in remission
    AND
    • Failure or clinically significant adverse effects to a one-month course of aminosalicylates (e.g. sulfasalazine, mesalamine) followed by corticosteroids such as prednisone.

    OR [for Entyvio, Inflectra]

    • Failure or clinically significant adverse effects to Remicade
    For maintenance:
    • Failure or clinically significant adverse effects to one of the following:
      • azathioprine
      • 6-mercaptopurine (6-MP)
      • aminosalicylates (e.g., sulfasalazine)

    Plaque Psoriasis [for Cosentyx, Enbrel, Humira, Inflectra, Otezla, Remicade, Stelara, Taltz]

    • Diagnosis of chronic moderate to severe plaque psoriasis
    AND
    • Prescribed by a Dermatologist or Rheumatologist
    AND
    • Failure or clinically significant adverse effects to ONE of the following therapies either alone or in combination, unless contraindicated:
      • Methotrexate up to a dose of 15-20 mg/week
    OR
      • If methotrexate is contraindicated, failure or clinically significant adverse effects to PUVA Therapy or UVB, cyclosporine or acitretin

    Polyarticular Juvenile Idiopathic Arthritis [for Actemra, Enbrel, Humira, Orencia (IV only)]

    • Diagnosis of Active Polyarticular Juvenile Idiopathic Arthritis
    AND
    • Confirmed by a Rheumatologist
    AND
    • Failure or clinically significant adverse effects to methotrexate for 3 months

    Neonatal-Onset Multisystem Inflammatory Disease (NOMID) [Kineret only]

    • Diagnosis of Neonatal-onset multisystem inflammatory disease (NOMID) or chronic infantile neurological, cutaneous and articular syndrome (CINCA)

    Hidradenitis Suppurativa (HS) [Humira, Enbrel]:

    • Diagnosis of Hidradenitis Suppurativa (HS)
    AND
    • Prescribed by a Dermatologist or Rheumatologist or gastroenterologist

    AND

    • Documentation of Hurley stage II or stage III

    AND

    • Failure or clinically significant adverse effects to systemic antibiotic therapy unless intolerant or contraindicated

    AND [for Enbrel]

    • Failure or clinically significant adverse effects to Humira

    Systemic juvenile idiopathic arthritis (SJIA) (for IV Actemra only):

    • Diagnosis of Systemic juvenile idiopathic arthritis

    AND

    • Prescribed by a Dermatologist or Rheumatologist or gastroenterologist

    AND

    • Failure or clinically significant adverse effects to methotrexate at least 10 mg/m2 per week for 3 months. [only one DMARD required since MTX is the only DMARD with extensive pediatric safety data]

    Non-infectious Uveitis (UV) [for Humira only]:

    • Diagnosis of non-infectious intermediate, posterior, or panuveitis

    AND

    • Prescribed by an ophthalmologist or rheumatologist

    AND

    • Failure or clinically significant adverse effects to oral corticosteroids (e.g., prednisone)

    AND

    • Failure or clinically significant adverse effects to non-biologic immunosuppressive therapy (e.g., azathioprine, methotrexate, mycophenolate mofetil, cyclosporine, tacrolimus, cyclophosphamide, chlorambucil)

    Relapsing remitting multiple sclerosis (for Tysabri only):

    • Refer to Tysabri MS criteria.
  3. Coverage is Not Authorized For:
    • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
    • Combination use with Xeljanz or biological DMARDs such as TNF antagonists [Cimzia, Enbrel, Simponi, Remicade, Inflectra], interleukin-1 receptor (IL-1R) antagonists [Kineret], interleukin-6 receptor (IL-6R) antagonists [Actemra], anti-CD20 monoclonal antibodies [Rituxan] and selective co-stimulation modulators [Orencia] because of the possibility of increased immunosuppression, neutropenia and increased risk of infection.
  4. General Information:
    • ACR Classification criteria for RA (score-based algorithm: add score of categories A-D; a score of >/= 6/10 is needed for classification of a patient as having definite RA).
    A. Joint involvement (swollen or tender)
      • 1 large joint, score = 0
      • 2-10 large joints, score = 1
      • 1-3 small joints (with or without involvement of large joints), score = 2
      • 4-10 small joints (with or without involvement of large joints), score = 3
      • >10 joints (at least 1 small joint), score = 5
    B. Serology (at least 1 test result is needed for classification)
      • Negative RF (rheumatoid factor) andnegative ACPA (anti-citrullinated protein antibody), score = 0
      • Low-positive RF orlow-positive ACPA, score = 2
      • High-positive RF orhigh-positive ACPA, score = 3
    C. Acute-phase reactants (at least 1 test result is needed for classification)
      • Normal CRP (C-reactive protein) andnormal ESR (erythrocyte sedimentation rate), score = 0
      • Abnormal CRP orabnormal ESR, score = 1
    D. Duration of symptoms
      • < 6 weeks, score = 0
      • >/= 6 weeks, score = 1
    • In RA, failure of MTX or DMARD is defined as a contraindication or < 50% decrease in swollen joint count, < 50% decrease in tender joint count, and < 50% decrease in ESR, or < 50% decrease in CRP, or contraindication to at least 3 months of therapy with MTX at doses up to 25 mg per week or maximum tolerated dose.
    • These agents are immunosuppressive and have the potential to increase the risk of infection and reactivate latent, chronic infections. They should not be administered to patients with a clinically important infection. Caution should be used in patients with chronic infections or history of recurrent infection. If patient develops a serious infection these agents should be discontinued.
    • Several ankylosing spondylitis (AS) treatment guidelines call for a trial of 2 or 3 non-steroidal anti-inflammatory drugs (NSAID) prior to use of an anti-TNF agent. A two year trial showed that continuous NSAID use reduced radiographic progression of AS versus on demand use of NSAID.
    • Serious infections were seen in clinical studies with concurrent use of Kineret and another TNF-blocking agent, Enbrel, with no added benefit compared to Enbrel alone. Because of the nature of the adverse reactions with this combination therapy, similar toxicities may also result from combination of anakinra and other TNF blocking agents.
    • For Ulcerative Colitis maintenance therapy, failure is defined as having two or more exacerbations requiring steroid therapy.
    • Failure of MTX in PJIA is defined as disease activity remaining moderate to high despite treatment with MTX.
    • In PJIA, response to treatment is reflected by improvement of disease activity level and poor prognostic features including: reduction in the number of active joints, ESR or CRP, Physician global assessment, patient/parent global assessment, arthritis of the hip or cervical spine, positive RF or ACPA, radiographic damage.
    • Per prescribing information, Xeljanz should not be used in combination with biologic DMARDs [such as Kineret] or potent immunosuppressants such as azathioprine and cyclosporine. As stated in the black box warning, patients treated with Xeljanz are at increased risk for developing serious infections that may lead to hospitalization or death. Most patients who developed these infections were taking concomitant immunosuppressants such as MTX or corticosteroids.
    • Stelara is for subcutaneous administration and is intended for use under the guidance and supervision of a physician. After proper training in subcutaneous injection technique, a patient may self inject with Stelara if a physician determines that it is appropriate. Patients should be instructed to follow the directions provided in the Medication Guide.
    • In the PHOENIX 2 trial, dosing intensification of Stelara to every 8 weeks did not result in greater efficacy compared with continuing treatment every 12 weeks.
    • Other names used for NOMID are as follows: chronic infantile neurological, cutaneous and articular syndrome (CINCA), chronic neurologic, cutaneous, and articular syndrome, infantile onset multisystem inflammatory disease, IOMID syndrome, and Prieur-Griscelli syndrome.
    • Hidradenitis Suppurativa (HS) sometimes referred to as : "acne inversa, acne conglobata, apocrine acne, apocrinitis, Fox-den disease, hidradenitis axillaris, HS, pyodermia sinifica fistulans, Velpeaus disease, and Verneuil`s disease. "
    • In hidradenitis suppurativa, Hurley stages are used to determine severity of disease. Hurley stage II indicates moderate disease, and is characterized by recurrent abscesses, with sinus tracts and scarring, presenting as single or multiple widely separated lesions. Hurley stage III indicates severe disease, and is characterized by diffuse or near-diffuse involvement presenting as multiple interconnected tracts and abscesses across an entire area.
    • Taltz is currently being studied for the treatment of rheumatoid arthritis, radiographic axial spondyloarthritis, ankylosing spondylitis, and psoriatic arthritis.
  5. Therapeutic Alternatives:
    Drug Dosing Regimen Dose Limit/ Maximum Dose

    azathioprine (ImuranR)

    Crohn's
    100-250 mg PO daily

    Rheumatoid Arthritis

    1 mg/kg/day PO given as a single dose or in divided doses twice daily

    Crohn's
    2.5 mg/kg/day

    Rheumatoid Arthritis

    2.5 mg/kg/day

    corticosteroids

    Crohn`s
    Prednisone 40 mg PO QD for 2 weeks or
    IV 50-100 mg Q6H for 1 week
    budesonide (Entocort ECR) 6-9 mg PO daily

    Varies

    hydroxychloroquine (PlaquenilR)
    Rheumatoid Arthritis
    Initial dose:
    400-600 mg PO QD
    Maintenance dose:
    200-400 mg PO QD

    600 mg/day

    mercaptopurine

    Crohn's Disease, Ulcerative Colitis
    75-125 mg PO QD

    1.5 mg/kg/day

    methotrexate (RheumatrexR)

    Rheumatoid Arthritis
    7.5 mg/week PO or 2.5 mg PO Q12hr for 3 doses/week
    Polyarticular Juvenile Arthritis
    10mg/m2 PO weekly
    Plaque Psoriasis
    10 to 25 mg/week, IM, IV or PO

    30 mg/week

    PentasaR (mesalamine)

    Crohn`s Disease and Ulcerative Colitis
    1000 mg PO QID

    4000 mg/day

    sulfasalazine (AzulfidineR)

    Rheumatoid Arthritis
    2 gm/day PO in divided doses

    Ulcerative Colitis
    Initial dose is 3 to 4 gm/day PO; maintenance is 2 gms/day PO
    Administer in evenly divided doses (not exceeding 8-hour intervals)

    4 gm/day

    cyclosporine (SandimmuneR, NeoralR)

    Rheumatoid Arthritis, Plaque Psoriasis
    2.5 - 4 mg/kg/day PO divided BID

    4 mg/kg/day

    Acitretin (Soriatane)

    Plaque Psoriasis
    25 or 50 mg PO daily

    50 mg/day

    doxycycline

    Hidradenitis suppurativa
    50-100 mg PO BID
    Up to 3 months

    minocycline

    Hidradenitis suppurativa
    50-100 mg PO BID
    Up to 3 months

    clindamycin+rifampin

    Hidradenitis suppurativa
    clindamycin 300 mg PO BID with rifampin 300 mg PO BID
    10 weeks
    * Requires Prior Authorization
  6. Recommended Dosing Regimen and Authorization Limit:
    Drug Dosing Regimen Authorization Limit

    See next column

    Rheumatoid Arthritis:
    ACTEMRA
    Intravenous
    4 mg/kg by IV infusion every 4 weeks, followed by an increase to 8 mg/kg based on clinical response

    Subcutaneous
    Under 100 kg weight: 162 mg SC every other week, followed by an increase to every week based on clinical response
    100 kg or greater weight: 162 mg SC every week

    When transitioning from Actemra IV therapy to SC administration, administer the first subcutaneous dose instead of the next scheduled intravenous dose.

    Dose reductions or interruptions may be necessary based on laboratory results for ANC, platelet count, and transaminases.

    CIMZIA
    Initial Dose: 400 mg SC initially and at Weeks 2 and 4
    Maintenance dose: 200 mg SC every other week (400 mg SC every 4 weeks can be considered)

    ENBREL
    50 mg SC once weekly

    HUMIRA
    40 mg SC every other week
    If not on concomitant methotrexate, may benefit from increasing the dosing frequency to 40 mg SC every week.

    KINERET
    100 mg/day by SC injection.

    ORENCIA

    Weight based IV infusion:
    < 60 kg: 500 mg
    60 - 100 kg: 750 mg
    >100 kg: 1000 mg

    Following initial administration, repeat dose at weeks 2 and 4, then every 4 weeks

    Subcutaneous use for adult rheumatoid arthritis:
    After a single IV infusion as a loading dose (as per body weight categories above), 125 mg administered by a SC injection should be given within a day, followed by 125 mg SC once a week.
    Patients who are unable to receive an infusion may initiate weekly SC injections without an IV loading dose.
    Patients transitioning from IV therapy to SC administration should administer the first SC dose instead of the next scheduled IV dose.

    REMICADE, INFLECTRA
    3 mg/kg IV initially and at weeks 2 and 6, then Q8W

    SIMPONI
    50 mg SC once a month

    SIMPONI ARIA
    2 mg/kg IV infusion over 30 minutes at weeks 0 and 4, then every 8 weeks

    Xeljanz
    5 mg PO BID

    Xeljanz XR
    11 mg PO QD
    Do not crush, split, or chew Xeljanz XR.
    3 months initial trial

    Continued treatment will be approved up to one year with documentation of response to therapy.

    Approval of Humira dose escalation to 40 mg weekly will require documentation of partial response to every other week dosing.

    XELJANZ/XELJANZ XR: Length of benefit

    See next column

    Ankylosing spondylitis:
    CIMZIA
    Initial dose: 400 mg SC initially and at Weeks 2 and 4
    Maintenance dose: 200 mg SC every other week (400 mg SC every 4 weeks can be considered)

    COSENTYX
    Initial dose:
    150 mg SC at Weeks 0, 1, 2, 3 and 4 (or option for no loading dose)
    Maintenance dose: 150 mg SC every 4 weeks

    ENBREL
    50 mg SC once weekly

    HUMIRA
    40 mg SC every other week

    REMICADE, INFLECTRA
    5 mg/kg IV initially and at weeks 2 and 6, then Q6W

    SIMPONI
    50 mg SC once a month

    3 months initial trial

    Continued treatment will be approved up to one year with documentation of response to therapy.

    See next column

    Psoriatic arthritis:
    CIMZIA
    Initial dose: 400 mg SC initially and at Weeks 2 and 4
    Maintenance dose: 200 mg SC every other week (400 mg SC every 4 weeks can be considered)

    COSENTYX
    Initial dose:
    150 mg SC at Weeks 0, 1, 2, 3 and 4 (or option for no loading dose)
    Maintenance dose: 150 mg SC every 4 weeks (can increase to 300 mg if needed)

    ENBREL
    50 mg SC once weekly

    HUMIRA
    40 mg SC every other week

    OTEZLA
    30 mg PO BID after initial titration dosing

    REMICADE, INFLECTRA
    5 mg/kg IV initially and at weeks 2 and 6, then Q8W

    SIMPONI
    50 mg SC once a month

    STELARA
    45 mg SC initially and 4 weeks later, followed by 45 mg every 12 weeks
    With co-existent moderate-to-severe plaque psoriasis weighing more than 100 kg:
    90 mg SC initially and 4 weeks later, followed by 90 mg SC every 12 weeks

    3 months initial trial

    Continued treatment will be approved up to one year with documentation of response to therapy.

    Otezla: Length of Benefit

    See next column

    Crohn's Disease:
    CIMZIA
    Initial dose: 400 mg SC initially and at weeks 2 and 4
    Maintenance dose: In patients who obtain a clinical response, 400 mg SC every 4 weeks

    ENTYVIO
    300 mg in 250ml NS IV over 30 minutes week 0, 2, 6, then q8w

    HUMIRA
    Adults
    Induction: 160 mg SC (four 40mg injections) day 1 followed by 80 mg SC 2 weeks later (day15). 160mg can be given as 4 injections in one day or divided over 2 days. Two weeks later (day 29) begin maintenance dose of 40mg SC every other week
    Maintenance: 40 mg SC every other week

    Pediatric
    17 kg to less than 40 kg
    Induction:80 mg (two 40mg injections) day 1 followed by 40 mg 2 weeks later (day15). Two weeks later (day 29) begin maintenance dose.
    Maintenance:20 mg every other week
    40 kg or greater
    Same as adult dosing

    REMICADE, INFLECTRA
    5 mg/kg IV initially and at weeks 2 and 6, then Q8W

    STELARA
    A single intravenous infusion using weight-based dosing:
    Up to 55kg: 260 mg
    55  85kg: 390 mg
    >85kg: 520 mg

    A subcutaneous 90 mg dose 8 weeks after the initial intravenous dose, then every 8 weeks thereafter.

    TYSABRI
    300 mg IV Q4W

    3 months initial trial.

    Continued treatment will be approved up to one year, upon receiving written documentation of clinical remission or response

    See next column

    Ulcerative Colitis Induction:
    ENTYVIO
    300 mg in 250ml NS IV over 30 minutes week 0, 2, 6, then q8w

    HUMIRA
    • Initial dose (Day 1): 160 mg SC (four 40 mg injections in one day or two 40 mg injections per day for two consecutive days)
    • Second dose two weeks later (Day 15): 80 mg SC
    • Two weeks later (Day 29): Begin a maintenance dose of 40 mg SC every other week
    Maintenance:
    40 mg SC every other week

    REMICADE, INFLECTRA
    5 mg/kg IV initially and at weeks 2 and 6, then Q8W

    SIMPONI
    200 mg SC at week 0, 100 mg SC at week 2, then 100 mg SC every 4 weeks

    3 months initial trial

    Continued treatment will be approved up to one year with documentation of clinical remission or response

    See next column

    Plaque Psoriasis:

    COSENTYX
    Initial dose: 300 mg SC at Weeks 0, 1, 2, 3 and 4
    Maintenance dose: 300 mg SC every 4 weeks. For some patients, a dose of 150 mg may be acceptable.

    ENBREL
    Adults:
    Starting dose: 25 mg or 50 mg SC twice weekly for 3 months
    Maintenance dose: 25 mg or 50 mg SC per week
    Pediatric:
    Less than 63 kg: 0.8 mg/kg SC per week given as single injection. Maximum dose of 50 mg per week
    63 kg or more: 50 mg SC per week

    HUMIRA
    Initial dose of 80 mg SC followed by 40 mg SC every other week starting one week after the initial dose.

    OTEZLA
    30 mg PO BID after initial titration dosing

    REMICADE, INFLECTRA
    5 mg/kg IV initially and at weeks 2 and 6, then Q8W

    STELARA
    Equal or less than 100 kg: 45 mg SC initially and 4 weeks later, followed by 45 mg every 12 weeks
    Greater than 100 kg: 90 mg SC initially and 4 weeks later, followed by 90 mg every 12 weeks

    TALTZ:
    160 mg (two 80 mg injections) SC at Week 0, followed by 80 mg at Weeks 2, 4, 6, 8, 10, and 12, then 80 mg SC every 4 weeks
    3 months initial trial

    Continued treatment will be approved up to one year with documentation of response to therapy.

    See next column

    Polyarticular Juvenile Idiopathic Arthritis:
    ACTEMRA
    Patients less than 30 kg: 10 mg/kg by IV infusion every 2 weeks
    Patients at or above 30 kg: 8 mg/kg by IV infusion every 2 weeks

    ENBREL
    Less than 63 kg: 0.8 mg/kg SC per week given as single injection. Maximum dose of 50 mg per week
    63 kg or more: 50 mg SC per week

    HUMIRA
    10 kg to less than 15 lg = 10 mg every other week
    10 kg to <15 kg = 10 mg SC every other week
    15 kg to <30 kg = 20 mg SC every other week
    ≥30 kg = 40 mg SC every other week

    ORENCIA
    Weight based IV infusion:

    < 75 kg: 10 mg/kg IV
    Dose as an adult for > 75 kg
    75 - 100 kg: 750 mg IV
    >100 kg: 1000 mg IV
    (maximum dose = 1,000 mg)

    Following initial administration, repeat dose at weeks 2 and 4, then every 4 weeks

    3 months initial trial.

    Continued treatment will be approved up to one year with documentation of response to therapy

    Kineret

    Neonatal-Onset Multisystem Inflammatory Disease (NOMID)
    1-2 mg/kg/day by SC injection. Maximum of 8 mg/kg daily.
    Once daily administration is generally recommended, but the dose may be split into twice daily administrations.

    Length of Benefit

    See next column

    Hidradenitis Suppurativa (HS):

    HUMIRA
    • Initial dose (Day 1): 160 mg SC (given as four 40 mg injections on Day 1 or as two 40 mg injections per day on Days 1 and 2)
    • Second dose two weeks later (Day 15): 80 mg SC (two 40 mg injections in one day)
    • Third (Day 29) and subsequent doses: 40 mg SC every week.

    ENBREL
    25-50 mg SC twice weekly

    One year
    See next column

    Systemic Juvenile Idiopathic Arthritis:

    ACTEMRA:
    Patients less than 30 kg: 12 mg/kg by IV infusion every 2 weeks
    Patients at or above 30 kg: 8 mg/kg by IV infusion every 2 weeks

    3 months initial trial.

    Continued treatment will be approved up to one year with documentation of response to therapy.

    TysabriMultiple Sclerosis
    300 mg IV Q 4 Wks
    3 months initial trial.

    Continued treatment will be approved up to one year with documentation of response to therapy.
    HumiraUveitis
    Initial dose of 80 mg SC followed by 40 mg SC every other week starting one week after the initial dose.
    3 months initial trial.

    Continued treatment will be approved up to one year with documentation of response to therapy.
  7. Product Availability:
    ACTEMRA single use vial, 80 mg/4 mL, 200 mg/10 mL, 400 mg/20 mL; 162 mg/0.9mL prefilled syringe

    CIMZIA
    Vial: 200 mg lypholized powder
    Single-use prefilled syringe: 200 mg/mL

    COSENTYX
    Vial:
    150 mg lyophilized powder (for healthcare professional use only)
    Syringe: 150 mg/ml; carton of 1 or 2 syringes
    Pen: 150 mg/ml (SensoreadyR); carton of 1 or 2 pens

    ENBREL
    Multi-use vials: 25 mg
    Single-use pre-filled syringes: 25 and 50 mg
    Pre-filled SureClick Autoinjector: 50 mg

    ENTYVIO
    single use vial, 300 mg/20 mL

    HUMIRA
    Pre-filled Pen Kit: 2 dose trays. Each dose tray contains a single-use 40mg/0.8ml pen.
    Crohn`s Disease Starter Package: 6 dose trays. Each dose tray contains a single-use 40mg/0.8ml prefilled pen.
    Psoriasis/Uveitis Starter Package: 4 dose trays. Each dose tray contains a single-use 40mg/0.8ml prefilled pen.
    Psoriasis/Uveitis Starter Package: 4 dose trays. Each dose tray contains a single-use 40mg/0.4ml prefilled pen.
    Pre-filled Syringe Kit: 40mg: 2 dose trays. Each dose tray contains a single-use 40mg/0.8ml prefilled syringe.
    Pediatric Pre-filled Syringe Kit: 20 mg: 2 dose trays. Each dose tray contains a single-use 20mg/0.4ml prefilled syringe.
    Pediatric Pre-filled Syringe Kit: 10 mg: 2 dose trays. Each dose tray contains a single-use 10 mg/0.2 mL prefilled syringe.

    INFLECTRA
    Single use vial: 100 mg/10 mL

    KINERET
    Prefilled glass syringe: 100 mg/0.67 ml (single-use)

    ORENCIA single use vial, 250 mg/15 mL; 125 mg/1 mL prefilled syringe

    OTEZLA 30 mg tablet; 14 day and 28 day starter kits containing 10 mg, 20 mg and 30 mg tablets

    REMICADE
    single use vial, 100 mg/10 mL

    SIMPONI
    Single dose prefilled SmartJect autoinjector: 50 mg/0.5 mL and 100mg/1mL
    Single dose prefilled syringe: 50 mg/0.5 mL and 100mg/1mL

    SIMPONI ARIA
    Vial: 50 mg/4 mL (12.5 mg/ml)

    STELARA
    Single-use prefilled syringe: 45 mg/0.5 mL or 90mg/1mL
    Single-use glass vial: 45 mg/0.5 mL or 90 mg/1 mL

    TALTZ
    Autoinjector 80 mg/mL solution in a single-dose prefilled autoinjector
    Prefilled Syringe 80 mg/mL solution in a single-dose prefilled syringe

    TYSABRI single use vial, 300 mg/15 mL

    XELJANZ Tablet: 5 mg

    XELJANZ XR Tablet: 11 mg
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The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.