Prior Authorization : Preferred Drug List

Cytokine and Cell Adhesion Molecule Antagonist Drugs

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Clinical PA is required for non-preferred cytokine and CAM antagonist drugs.

PA requests for non-preferred cytokine and CAM antagonist drugs will only be approved for use to treat the following identified clinical conditions:

• Ankylosing spondylitis
• Crohn's disease
• ERA
• DIRA
• Giant cell arteritis
• Hidradenitis suppurativa
• JIA and systemic JIA
• NMOSD
• NOMID
• nr-axSpA
• PMR
• Psoriasis
• Psoriatic arthritis
• RA
• SSc-ILD
• Ulcerative colitis
• Uveitis

Otezla, a preferred drug in the cytokine and CAM antagonist drug class, is the only cytokine and CAM antagonist drug indicated for the clinical condition of oral ulcers associated with Behcet's disease. Preferred drugs do not require PA.

Biosimilar drug products to Humira are non-preferred drugs in the cytokine and CAM antagonists drug class.

Note: Adalimumab is the generic drug name for Humira, and each individual biosimilar for Humira is named with a specific four-letter designation placed after adalimumab. ForwardHealth uses a blanket "xxxx" placeholder after adalimumab (adalimumab-xxxx) when referring to the non-preferred Humira biosimilar drug products in the clinical PA criteria for the appropriate clinical condition. The Preferred Drug List Quick Reference pharmacy data table lists the brand names with the complete generic names of the non-preferred Humira biosimilar drug products in the cytokine and CAM antagonists drug class.

PA requests for cytokine and CAM antagonist drugs will only be approved for one cytokine and CAM antagonist drug per member. ForwardHealth does not cover treatment with more than one cytokine and CAM antagonist drug.

PA requests will not be considered for subcutaneous dosage forms of cytokine and CAM antagonist drugs that will be administered in a medical office or medical facility.

Supporting clinical information and a copy of the member's current medical records must be submitted with all PA requests for non-preferred cytokine and CAM antagonist drugs. The supporting clinical information and medical records must document the following:

• The member's medical condition being treated
• Details regarding previous medication use
• The member's current treatment plan

Initial PA requests for non-preferred cytokine and CAM antagonist drugs may be approved for up to 183 days.

Renewal PA requests for non-preferred cytokine and CAM antagonist drugs may be approved for up to 365 days. Renewal PA requests for non-preferred cytokine and CAM antagonist drugs must include supporting clinical information and copies of the member's current medical records demonstrating that the member had a significant reduction in symptoms compared to their baseline prior to the initiation of the non-preferred cytokine and CAM antagonist drug.

All renewal PA requests require the member to be adherent with the prescribed treatment regimen.

For information about general ForwardHealth PA policy for drugs that require PA approval, prescribers and pharmacy providers may refer to the Standard Pharmacy Policy for Covered and Noncovered Drugs topic. Providers may also refer to this topic for information about what may not be considered criteria to support the need for a drug.

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Ankylosing Spondylitis

Enbrel, Humira, and Xeljanz are preferred drugs used to treat ankylosing spondylitis. Preferred drugs do not require PA.

Adalimumab-xxxx, Cimzia, Cosentyx subQ, Rinvoq, Simponi subQ, Taltz, and Xeljanz XR are non-preferred drugs used to treat ankylosing spondylitis.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat ankylosing spondylitis are all of the following:

• The member has ankylosing spondylitis.
• The prescription is written by a rheumatologist or through a rheumatology consultation.
• The member has taken two preferred cytokine and CAM antagonist drugs for at least three consecutive months each and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Xeljanz XR

The prescriber must submit detailed clinical justification for prescribing Xeljanz XR instead of Xeljanz. The clinical information must document why the member cannot use Xeljanz, including why it is medically necessary that the member receive Xeljanz XR instead of Xeljanz.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Ankylosing Spondylitis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat ankylosing spondylitis must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Ankylosing Spondylitis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Ankylosing Spondylitis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat ankylosing spondylitis may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Crohn's Disease

Humira is a preferred drug used to treat Crohn's disease. Preferred drugs do not require PA.

Adalimumab-xxxx, Cimzia, Rinvoq, Skyrizi subQ, and Stelara subQ are non-preferred drugs used to treat Crohn's disease.

Note: Skyrizi and Stelara will require an IV induction prior to initiating treatment with the subQ. A PA request for the IV induction must be approved before ForwardHealth will consider PA for the subQ. PA for the IV induction may be obtained through the physician-administered drug PA process.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat Crohn's disease are all of the following:

• The member has Crohn's disease.
• The prescription is written by a gastroenterologist or through a gastroenterology consultation.
• The member has taken one preferred cytokine and CAM antagonist drug for at least three consecutive months and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Crohn's Disease

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat Crohn's disease must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Crohn's Disease and Ulcerative Colitis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Crohn's Disease and Ulcerative Colitis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat Crohn's disease may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and CAM Antagonist Drugs for Deficiency of Interleukin-1 Receptor Antagonist

Kineret is a non-preferred drug used to treat DIRA.

Clinical criteria for approval of a PA request for Kineret used to treat DIRA are both of the following:

• The member has DIRA.
• The prescription is written by or through consultation with a DIRA specialist (for example, an immunologist or a rheumatologist).

Clinical documentation and medical records must be submitted with the PA request to support the member's condition of DIRA and outline the member's current treatment plan for DIRA.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Deficiency of Interleukin-1 Receptor Antagonist

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat DIRA must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form and a completed PA/RF to ForwardHealth.

PA requests for Kineret used to treat DIRA may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Enthesitis-Related Arthritis

Cosentyx subQ is a non-preferred drug used to treat ERA.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat ERA are both of the following:

• The member has ERA.
• The prescription is written by a rheumatologist or through a rheumatology consultation.

Clinical documentation and medical records must be submitted with the PA request to support the member's condition of ERA and outline the member's current treatment plan for ERA.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Enthesitis-Related Arthritis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat ERA must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat ERA may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system.)

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Giant Cell Arteritis

Actemra subQ solution is a non-preferred drug used to treat giant cell arteritis.

Clinical criteria for approval of a PA request for Actemra subQ solution used to treat giant cell arteritis are both of the following:

• The member has giant cell arteritis.
• The prescription is written by a rheumatologist or through a rheumatology consultation.

Clinical documentation and medical records must be submitted with the PA request to support the member's condition of giant cell arteritis and outline the member's current treatment plan for giant cell arteritis.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Giant Cell Arteritis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat giant cell arteritis must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form and a completed PA/RF to ForwardHealth.

PA requests for Actemra subQ solution used to treat giant cell arteritis may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Hidradenitis Suppurativa

Humira is a preferred drug used to treat hidradenitis suppurativa. Preferred drugs do not require PA.

Adalimumab-xxxx and Cosentyx subQ are non-preferred drugs used to treat hidradenitis suppurativa.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat hidradenitis suppurativa are all of the following:

• The member has hidradenitis suppurativa.
• The prescription is written by a dermatologist or through a dermatology consultation.
• The member has taken one preferred cytokine and CAM antagonist drug for at least three consecutive months and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Hidradenitis Suppurativa

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat hidradenitis suppurativa must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Hidradenitis Suppurativa form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Hidradenitis Suppurativa form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat hidradenitis suppurativa may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Neuromyelitis Optica Spectrum Disorder

Enspryng is a non-preferred drug used to treat NMOSD.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat NMOSD are all of the following:

• The member has NMOSD.
• The prescription is written by a neurologist or through a neurology consultation.
• The member is anti-aquaporin-4 antibody positive.

Clinical documentation and medical records must be submitted with the PA request to support the member's clinical condition of NMOSD and outline the member's current treatment plan for NMOSD.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Neuromyelitis Optica Spectrum Disorder

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat NMOSD must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat NMOSD may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system.)

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Neonatal Onset Multisystem Inflammatory Disease

Kineret is a non-preferred drug used to treat NOMID.

Clinical criteria for approval of a PA request for Kineret used to treat NOMID are both of the following:

• The member has NOMID.
• The prescription is written by a rheumatologist or through a rheumatology consultation.

Clinical documentation and medical records must be submitted with the PA request to support the member's condition of NOMID and outline the member's current treatment plan for NOMID.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Neonatal Onset Multisystem Inflammatory Disease

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat NOMID must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form and a completed PA/RF to ForwardHealth.

PA requests for Kineret used to treat NOMID may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Non-Radiographic Axial Spondyloarthritis

Cimzia, Cosentyx subQ, Rinvoq, and Taltz are non-preferred drugs used to treat nr-axSpA.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat nr-axSpA are both of the following:

• The member has nr-axSpA.
• The prescription is written by a rheumatologist or through a rheumatology consultation.

Clinical documentation and medical records must be submitted with the PA request to support the member's condition of nr-axSpA and outline the member's current treatment plan for nr-axSpA.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Non-Radiographic Axial Spondyloarthritis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat nr-axSpA must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for DIRA, Giant Cell Arteritis, NOMID, and nr-axSpA form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat nr-axSpA may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Polymyalgia Rheumatica

Kevzara is a non-preferred cytokine and CAM antagonist drug used to treat PMR.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat PMR are all of the following:

• The member has PMR.
• The prescription is written by or through consultation with a PMR specialist.
• The member has taken corticosteroids and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.

Clinical documentation and medical records must be submitted with the PA request to support the member's condition of PMR and outline the member's current treatment plan for PMR.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Polymyalgia Rheumatica

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat PMR must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat PMR may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Psoriasis

Enbrel, Humira, and Otezla are preferred drugs used to treat psoriasis. Preferred drugs do not require PA.

Adalimumab-xxxx, Bimzelx, Cimzia, Cosentyx subQ, Siliq, Skyrizi subQ, Sotyktu, Stelara subQ, Taltz, and Tremfya are non-preferred drugs used to treat psoriasis.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat psoriasis are all of the following:

• The member has psoriasis.
• The prescription is written by a dermatologist or through a dermatology consultation.
• The member has taken two preferred cytokine and CAM antagonist drugs for at least three consecutive months each and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Psoriasis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat psoriasis must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Psoriasis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Psoriasis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat psoriasis may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Psoriatic Arthritis

Enbrel, Humira, Orencia subQ, Otezla, and Xeljanz are preferred drugs used to treat psoriatic arthritis. Preferred drugs do not require PA.

Adalimumab-xxxx, Cimzia, Cosentyx subQ, Rinvoq, Simponi subQ, Skyrizi subQ, Stelara subQ, Taltz, Tremfya, and Xeljanz XR are non-preferred drugs used to treat psoriatic arthritis.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat psoriatic arthritis are all of the following:

• The member has psoriatic arthritis.
• The prescription is written by a dermatologist or rheumatologist or through a dermatology or rheumatology consultation.
• The member has taken two preferred cytokine and CAM antagonist drugs for at least three consecutive months each and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Xeljanz XR

The prescriber must submit detailed clinical justification for prescribing Xeljanz XR instead of Xeljanz. The clinical information must document why the member cannot use Xeljanz, including why it is medically necessary that the member receive Xeljanz XR instead of Xeljanz.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Psoriatic Arthritis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat psoriatic arthritis must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for RA, JIA, and Psoriatic Arthritis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for RA, JIA, and Psoriatic Arthritis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat psoriatic arthritis may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Rheumatoid Arthritis

Enbrel, Humira, Orencia subQ, and Xeljanz are preferred drugs used to treat RA. Preferred drugs do not require PA.

Actemra subQ, adalimumab-xxxx, Cimzia, Kevzara, Kineret, Olumiant, Rinvoq, Simponi subQ, and Xeljanz XR are non-preferred drugs used to treat RA.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat RA are all of the following:

• The member has RA.
• The prescription is written by a rheumatologist or through a rheumatology consultation.
• The member has taken two preferred cytokine and CAM antagonist drugs for at least three consecutive months each and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction. Additionally, for PA requests for Simponi subQ solution, members must also continue to take methotrexate in combination with Simponi subQ solution.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Xeljanz XR

The prescriber must submit detailed clinical justification for prescribing Xeljanz XR instead of Xeljanz. The clinical information must document why the member cannot use Xeljanz, including why it is medically necessary that the member receive Xeljanz XR instead of Xeljanz.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Rheumatoid Arthritis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat RA must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for RA, JIA, and Psoriatic Arthritis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for RA, JIA, and Psoriatic Arthritis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat RA may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Juvenile Idiopathic Arthritis

Enbrel, Humira, Orencia subQ, and Xeljanz are preferred drugs used to treat JIA. Preferred drugs do not require PA.

Actemra subQ, adalimumab-xxxx, and Xeljanz Oral Solution are non-preferred drugs used to treat JIA.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat JIA are all of the following:

• The member has JIA.
• The prescription is written by a rheumatologist or through a rheumatology consultation.
• The member has taken two preferred cytokine and CAM antagonist drugs for at least three consecutive months each and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Xeljanz Oral Solution

The prescriber must submit detailed clinical justification for prescribing Xeljanz Oral Solution instead of Xeljanz. The clinical information must document why the member cannot use Xeljanz, including why it is medically necessary that the member receive Xeljanz Oral Solution instead of Xeljanz.

Clinical Criteria for Systemic Juvenile Idiopathic Arthritis

Actemra subQ is a non-preferred drug used to treat systemic JIA.

Clinical criteria for approval of a PA request for Actemra subQ solution used to treat systemic JIA are both of the following:

• The member has systemic JIA.
• The prescription is written by a rheumatologist or through a rheumatology consultation.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Juvenile Idiopathic Arthritis and Systemic Juvenile Idiopathic Arthritis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat JIA and systemic JIA must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for RA, JIA, and Psoriatic Arthritis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for RA, JIA, and Psoriatic Arthritis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat JIA and systemic JIA may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Systemic Sclerosis-Associated Interstitial Lung Disease

Actemra subQ is a non-preferred drug used to treat SSc-ILD.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat SSc-ILD are both of the following:

• The member has SSc-ILD.
• The prescription is written by or through consultation with an SSc-ILD specialist.

Clinical documentation and medical records must be submitted with the PA request to support the member's condition of SSc-ILD and outline the member's current treatment plan for SSc-ILD.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Systemic Sclerosis-Associated Interstitial Lung Disease

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat SSc-ILD must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat SSc-ILD may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system.)

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Ulcerative Colitis

Humira and Xeljanz are preferred drugs used to treat ulcerative colitis. Preferred drugs do not require PA.

Adalimumab-xxxx, Entyvio subQ, Omvoh subQ, Rinvoq, Simponi subQ, Stelara subQ, and Xeljanz XR are non-preferred drugs used to treat ulcerative colitis.

Note: Stelara will require an IV induction prior to initiating treatment with the subQ. A PA request for the IV induction must be approved before ForwardHealth will consider PA for the subQ. PA for the IV induction may be obtained through the physician-administered drug PA process.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat ulcerative colitis are all of the following:

• The member has ulcerative colitis.
• The prescription is written by a gastroenterologist or through a gastroenterology consultation.
• The member has taken two preferred cytokine and CAM antagonist drugs for at least three consecutive months each and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber must submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Xeljanz XR

The prescriber must submit detailed clinical justification for prescribing Xeljanz XR instead of Xeljanz. The clinical information must document why the member cannot use Xeljanz, including why it is medically necessary that the member receive Xeljanz XR instead of Xeljanz.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Ulcerative Colitis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat ulcerative colitis must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Crohn's Disease and Ulcerative Colitis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Crohn's Disease and Ulcerative Colitis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat ulcerative colitis may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Uveitis

Humira is a preferred drug used to treat uveitis. Preferred drugs do not require PA.

Adalimumab-xxxx is a non-preferred drug used to treat uveitis.

Clinical criteria for approval of a PA request for non-preferred cytokine and CAM antagonist drugs used to treat uveitis are all of the following:

• The member has uveitis.
• The prescription is written by an ophthalmologist or through an ophthalmology consultation.
• The member has taken one preferred cytokine and CAM antagonist drug for at least three consecutive months and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The prescriber has indicated the clinical reason(s) why a non-preferred cytokine and CAM antagonist drug is being requested.

Adalimumab-xxxx

The prescriber is required to submit detailed clinical justification for prescribing adalimumab-xxxx instead of Humira. The clinical information must document why the member cannot use Humira, including why it is medically necessary that the member receive adalimumab-xxxx instead of Humira.

Submitting PA Requests for Cytokine and Cell Adhesion Molecule Antagonist Drugs for Uveitis

PA requests for non-preferred cytokine and CAM antagonist drugs must be completed, signed, and dated by the prescriber. PA requests for non-preferred cytokine and CAM antagonist drugs used to treat uveitis must be submitted using the Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Uveitis form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed Prior Authorization Drug Attachment for Cytokine and CAM Antagonist Drugs for Uveitis form and a completed PA/RF to ForwardHealth.

PA requests for non-preferred cytokine and CAM antagonist drugs used to treat uveitis may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).