- Quantity Limit: limit maximum 1 EA PER 1 day(s)
- Prior Authorization: Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
Rheumatoid Arthritis (RA):
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 1 plan year
Reauthorization Required: Yes
Ulcerative Colitis (UC):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 6 Month(s)
Reauthorization Required: Yes
- Limited Access. Must use AcariaHealth Specialty Rx.
- Ankylosing Spondylitis (AS):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: No
Psoriatic Arthritis (PsA):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Dermatologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
TB Test required: No
Rheumatoid Arthritis (RA):
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 1 plan year
TB Test required: No
Ulcerative Colitis (UC):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Gastroenterologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
TB Test required: No
- Step Therapy: Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Ulcerative Colitis (UC):
ST Multiple Generics
Psoriatic Arthritis (PsA):
ST Single Brand
- I. Health Net Approved Indications and Usage Guidelines: A. Rheumatoid Arthritis: 1. Diagnosis of rheumatoid arthritis (RA); AND 2. Confirmed by a Rheumatologist; OR 3. Defined at baseline prior to disease modifying anti-rheumatic drug (DMARD) treatment initiation by the (American College of Rheumatology (ACR)) criteria; AND 4. Failure or clinically significant adverse effects to methotrexate (MTX) in the last year for patients who are new to biologics; OR 5. 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 6. Failure or clinically significant adverse effects to a 3-month minimum trial of Humira AND either, Remicade or Simponi or Simponi Aria. II. Coverage is Not Authorized For: Combination use with Xeljanz or biological DMARDs because of the possibility of increased immunosuppression, neutropenia and increased risk of infection. II. Authorization Limit: 6 months or to members renewal date, whichever is longer.
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