CurrentCareSourcePolicy H6396_OH-SNP-M-4313298-V.5_C

Multiple drug-specific prior authorization criteria (Part 1 of 17)

Part of a multi-part CareSource drug prior authorization policy listing numerous medical-benefit drugs with indication-specific prior authorization criteria, exclusions, required information, age and prescriber restrictions, and coverage durations.

Policy Summary

PayerCareSource

PolicyMultiple drug-specific prior authorization criteria (Part 1 of 17)

Policy CodePolicy H6396_OH-SNP-M-4313298-V.5_C

Change TypeNo material change

Effective DateApr 1, 2026

Next Review Date

Key ActionThese drugs require prior authorization; submit diagnosis, concurrent medications, previous drug trials and relevant lab/imaging/genetic tests per drug-specific criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this policy part.

40+Products listed in this part

1 yrCommon authorization duration (most)

ManyRequire specialist prescriber/consult

SeveralRequire genetic/biomarker testing

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Scope: This file is one segment of a multi-part CareSource medical-benefit drug prior authorization policy covering numerous medical-benefit drugs with indication-specific PA criteria, exclusions, required information, age and prescriber restrictions, and coverage durations.

Coverage stance: Mixed — some products are covered when detailed criteria are met; many entries include exclusions and denial rules.

Common themes / operational points:

- Prior authorization required for listed drugs; prescribers must submit diagnosis, prior therapy history, and specified labs/genetic/biomarker tests when required.

- Specialist prescriber or consultation frequently required (examples: rheumatologist for Actemra; pulmonologist for Arikayce; oncologist for many oncology agents).

- Concurrent-use exclusions are common (e.g., no concurrent biologic DMARD/targeted synthetic DMARD; no combination with other CGRP inhibitors).

- Authorization durations are commonly 1 year or “through end of plan year”; some initial approvals are shorter (examples: 4 months, 6 months, 8 months).

- Continuation approvals typically require prescriber documentation of patient response/benefit.

Major drug categories included in this part:

- Oncology agents (targeted therapies, antibody–drug conjugates, immunotherapies) — multiple tumor- and biomarker-specific criteria (e.g., BRAF, RET, FGFR2, NTRK, MET, IDH, KRAS).

- Biologics / immunology (rheumatology, dermatology, gastroenterology) — many with step requirements and exclusion of concomitant biologics/JAK inhibitors.

- Neurology (antiepileptics, MS disease-modifying therapies, ALS, movement disorders).

- Pulmonology / CF / inhaled antibiotics (e.g., Arikayce, CFTR modulators, inhaled tobramycin).

- Rare metabolic and lysosomal disorders (enzyme replacement and genetic-test–driven approvals).

- Hematology (growth factors, ESAs, thrombopoietins, BTK/venetoclax-era agents, multiple myeloma regimens).

- Cardiometabolic and endocrine specialty drugs (PAH therapies requiring right-heart cath; osteoporosis agents with T-score thresholds).

Key operational reminders for implementers drawn from the part:

- Verify and capture required diagnostic tests or mutation status when specified (eg, BRAF V600, RET, FGFR2, IDH1/2, BRCA, CFTR).

- Enforce documented prior trials or intolerance where listed (step therapy or ‘try X before Y’ requirements).

- Apply explicit exclusions (concurrent agents, Medicare Part D vs ESRD/Part B rules) noted in product rules.

- Use the listed coverage durations and require documented clinical response for renewals.

Operational summary

Policy numberH6396_OH-SNP-M-4313298-V.5_C

Effective date2026-04-01

Typical authorization durationMost approvals: 1 year (many entries list 1 year or ‘approve through end of plan year’)

Common prescriber specialties requiredOften requires specialist prescription or consult: oncology, rheumatology, pulmonology, neurology, genetic/metabolic specialists

Part B vs Part D noteFor many oncology and certain specialty agents, Part B versus Part D determination is made at prior authorization review per CMS guidance

Initial Therapy Criteria (selected agents)

ACTEMRA INTRAVENOUS - Initial therapy criteria

Approve when ALL of the following are met:

ALL of the following

Diagnosis consistent with an FDA‑approved indication for intravenous tocilizumab (ACTEMRA IV).
Exclusion: No concurrent use with another biologic disease‑modifying antirheumatic drug (DMARD) or targeted synthetic DMARD (e.g., other biologic TNFi, JAK inhibitor).
Required information: documentation of diagnosis, current concurrent medications, and prior therapies tried.
Age / indication specific
- Giant cell arteritis (GCA) or rheumatoid arthritis (RA): age ≥ 18 years (initial therapy).
- Polyarticular juvenile idiopathic arthritis (PJIA) / systemic juvenile idiopathic arthritis (SJIA): age ≥ 2 years (initial therapy).
Prescriber restriction (initial therapy): prescribed by or in consultation with a rheumatologist for RA, SJIA, PJIA, GCA.
Coverage duration: approve through end of plan year (initial authorization).
RA / PJIA initial therapy prior-treatment rules
- RA initial: ONE of the following prior trials: etanercept (Enbrel), a preferred adalimumab product (e.g., Hadlima, Simlandi), upadacitinib (Rinvoq), or tofacitinib/XR (Xeljanz/XR). If none of these, prior trials with certolizumab (Cimzia), sarilumab (Kevzara), infliximab, golimumab SC/IV, abatacept (Orencia) or a non‑preferred adalimumab product may be counted.
- Or RA exception: history of heart failure or previously treated lymphoproliferative disorder.
- PJIA initial: ONE of the following prior trials: etanercept (Enbrel), upadacitinib (Rinvoq), tofacitinib (Xeljanz) or a preferred adalimumab product; alternates that may count include sarilumab (Kevzara), infliximab, abatacept (Orencia) or a non‑preferred adalimumab product.
- SJIA (systemic‑onset JIA): approve (initial).
Other covered indication: cytokine release syndrome associated with CAR T‑cell therapy — approve when indicated.
Continuation: approve if patient had a response as determined by the prescriber (all indications).

ACTEMRA ACTPEN / SUBCUTANEOUS - Initial therapy

Approve when ALL of the following are met:

ALL of the following

Diagnosis of an FDA‑approved indication for subcutaneous tocilizumab (ACTEMRA ACTPEN / ACTEMRA SUBCUTANEOUS).
Exclusion: No concurrent use with another biologic DMARD or targeted synthetic DMARD.
Age / indication
- Giant cell arteritis (GCA) / Rheumatoid arthritis (RA): age ≥ 18 years (initial therapy).
- Polyarticular juvenile idiopathic arthritis (PJIA) / Systemic juvenile idiopathic arthritis (SJIA): age ≥ 2 years (initial therapy).

ACTIMMUNE - Criteria

Approve when ALL of the following are met:

ALL of the following

Diagnosis of chronic granulomatous disease (CGD) or severe malignant osteopetrosis consistent with FDA‑approved indications for interferon gamma‑1b (ACTIMMUNE).
Diagnostic confirmation
- Chronic granulomatous disease: molecular genetic test identifying a pathogenic variant linked to CGD.
- Malignant osteopetrosis, severe: either radiographic (X‑ray) imaging demonstrating skeletal features related to osteopetrosis OR a molecular genetic test identifying a pathogenic variant linked to severe malignant osteopetrosis.
Prescriber restriction: CGD — prescribed by or in consultation with an immunologist, hematologist, or infectious disease specialist; malignant osteopetrosis — prescribed by or in consultation with an endocrinologist or hematologist.

Hadlima / Simlandi (adalimumab products) - Initial therapy

Approve when ALL of the following are met:

ALL of the following

Diagnosis consistent with an FDA‑approved indication for adalimumab products Hadlima or Simlandi (initial therapy).
Exclusion: No concurrent use with another biologic DMARD or targeted synthetic DMARD (including concurrent biologic or JAK inhibitors).
Age / indication specific limits
- Crohn's disease (CD): age ≥ 6 years (initial therapy).
- Ulcerative colitis (UC): age ≥ 5 years (initial therapy).

ADBRY (tralokinumab) - Atopic dermatitis initial and continuation

Initial therapy - approve when ALL of the following are met:

ALL of the following

Diagnosis of moderate‑to‑severe atopic dermatitis affecting ≥ 10% body surface area (BSA).
Exclusion: No concurrent use with another monoclonal antibody therapy (examples: dupilumab, mepolizumab, benralizumab, tezepelumab, omalizumab) or with a Janus kinase inhibitor (oral or topical) (examples: abrocitinib, leqseIvi, upadacitinib/rinvoq, topical tofacitinib/opzelura).
Age restriction (initial therapy): age ≥ 12 years.
Prescriber restriction (initial therapy): prescribed by or in consultation with an allergist, immunologist, or dermatologist.
Required prior topical therapy: patient has tried at least one medium‑, medium‑high, high‑, or super‑high‑potency prescription topical corticosteroid and demonstrated inadequate efficacy with that therapy.

Combined immunologic/biologic initial‑therapy pattern (examples: CIMZIA, ENBREL, COSENTYX, DUPIXENT)

Representative initial‑therapy structural rules for immunologic / biologic agents (apply in addition to indication‑specific criteria):

ALL of the following

Exclusion: No concurrent use with other biologic disease‑modifying antirheumatic drugs (DMARDs) or targeted biologic/targeted synthetic agents (examples include other biologic TNFi, IL‑targeted mAbs, JAK inhibitors) unless the product labeling or clinical program allows combination therapy.
Prescriber specialty requirement: initial prescriptions must be by or in consultation with an appropriate specialist for the indication (examples: rheumatologist for RA/JIA; dermatologist for psoriasis/HS; gastroenterologist for IBD; pulmonologist for certain lung disease indications; neurologist for select neurologic biologics).
Common age limits (examples)
- Pediatric JIA/JIA‑related indications: may require age ≥ 2 years.

Continuation Therapy Criteria

ACTEMRA INTRAVENOUS - Continuation therapy

Continuation approved when the following is met:

Continuation: Patient had a response to therapy as determined by the prescriber

Prescriber-determined response is required for continuation

ACTEMRA ACTPEN / SUBCUTANEOUS - Continuation therapy

Continuation criteria

Continuation: Patient had a response to therapy

Prescriber-determined response required

CONTINUATION THERAPY: ALL INDICATIONS

General continuation rule used across indications and products

General Continuation Therapy: Patient had a response to therapy

Continuation often requires documentation of benefit per prescriber; typical continuation durations are 1 year or through end of plan year unless otherwise specified (some initial approvals shorter, e.g., 4 months induction)

Exclusions / Not Covered

Explicit exclusions / disallow rules collected from brief

Explicit exclusions / disallow rules collected from the brief

Exclusions

No concurrent Biologic/Targeted Synthetic DMARD: No concurrent use with a Biologic DMARD or Targeted Synthetic DMARD (explicit exclusion in multiple biologic/RA/CIMZIA/Actemra/Infliximab entries)
Refs: Actemra, CIMZIA, Infliximab
No concurrent monoclonal antibody or JAK inhibitor: No concurrent use with another monoclonal antibody therapy or JAK inhibitors (e.g., for tralokinumab, dupilumab and some atopic dermatitis agents)
Ref: Adbry
No concurrent CGRP inhibitors: No concurrent combination therapy with another cGRP inhibitor for migraine prevention (e.g., Aimovig, Emgality, Qulipta exclusions)
Ref: Aimovig, Emgality, Qulipta
No concomitant CF cysteamine products: No concomitant use of Cystagon and Procysbi (explicit exclusion)
Ref: CYSTAGON
ESAs Medicare Part D ESRD exclusion: Anemia/ESRD-related denials: Erythropoiesis-stimulating agents for anemia in patients with chronic renal failure on dialysis are denied under Medicare Part D (claim should be submitted under ESRD bundled payment benefit)
Ref: RETACRIT / PROCRIT

Other common denial scenarios called out in the part include: Medicare Part D denials when treatment falls under the ESRD bundled benefit (e.g., cinacalcet for secondary hyperparathyroidism on dialysis), explicit exclusions for concurrent use of specified agents (e.g., no concurrent CGRP inhibitors with Aimovig/Qulipta/Emgality; no concurrent biologics or JAK inhibitors with many biologic entries), exclusions of cosmetic indications (e.g., topical / systemic agents for cosmetic weight gain), and exclusions of acute procedural or sedation uses for certain high-risk medications (HRMs) such as benzodiazepines or promethazine where sedation/insomnia use is disallowed.

Applicable Codes

Products listed in this part — mixedmixed

ZEPOSIA	Ozanimod (brand ZEPOSIA) — oral sphingosine 1‑phosphate receptor modulator
ZEPZELCA	Zepzelca (lurbinectedin) — IV antineoplastic agent
ZIIHERA	Ziihera — (specified biologic/agent)
ZOLINZA	Zolinza (vorinostat) — oral histone deacetylase inhibitor
ZTALMY	Ztalmy (zavegepant) — intranasal CGRP receptor antagonist
ZYDELIG	Zydelig (idelalisib) — oral PI3K inhibitor
ZYKADIA	Zykadia (ceritinib) — oral ALK inhibitor
ZYMFENTRA	Zymfentra — (specified biologic/agent)
ZYNLONTA	Zynlonta (loncastuximab tesirine) — antibody‑drug conjugate
ZYNYZ	Zynyz — (specified agent)

1–10 of 18

1/2

NDC-specific — ZURZUVAE ORAL CAPSULENDC

ZURZUVAE-20MG	ZURZUVAE oral capsule 20 mg
ZURZUVAE-25MG	ZURZUVAE oral capsule 25 mg
ZURZUVAE-30MG	ZURZUVAE oral capsule 30 mg

NDC-specific — abiraterone oral tabletNDC

ABIRATERONE-250MG	Abiraterone oral tablet 250 mg
ABIRATERONE-500MG	Abiraterone oral tablet 500 mg

Provider Actions — Prior Authorization & Documentation

Prior Authorization

Prior authorization required

Prior authorization is required for all drugs in this policy part; submit diagnosis, required lab/genetic test results, prior therapy history, and prescriber specialty as specified per drug. Part B vs Part D determinations will be made at prior authorization review for many oncology agents.

Examples of required molecular/genetic tests: BRAF V600 mutation (e.g., BRAFTOVI, MEKINIST, TAFINLAR) — see BRAFTOVI/MEKINIST/TAFINLAR criteria
RET gene rearrangement testing (e.g., CABOMETYX, COMETRIQ, GAVRETO) — see CABOMETYX/COMETRIQ/GAVRETO criteria
EGFR mutation testing (examples: exon 19 deletions, exon 21 L858R, L861Q, G719X, S768I) for EGFR-directed TKIs (e.g., erlotinib, gefitinib, Tagrisso)
CFTR genotyping/sweat chloride or nasal potential difference for CFTR modulators (e.g., Kalydeco, Orkambi, Trikafta)
FLT3/IDH/IDH2/ALK/MET/KRAS/NRG1 and other tumor biomarkers as specified per oncology agent
Microbiology/culture results where required (e.g., positive MAC sputum culture for Arikayce)
Functional C1-INH and C4 levels for HAE therapies (e.g., Cinryze)

Documentation Required

Document prior therapy trials and clinical response

Document dates, agents, reason for failure/intolerance, and objective evidence of benefit for continuation (lab values, imaging, functional scores, reduced exacerbations).

Migraine: reduction in migraine days/month (Aimovig/Emgality/Nurtec/Qulipta examples)
Arikayce (MAC): sputum culture results (positive MAC; negative cultures timeline for continuation)
Erythropoiesis-stimulating agents (ESAs): hemoglobin thresholds (e.g., Hb <10 g/dL for many initial indications; continuation thresholds ≤12 g/dL)
Interstitial lung disease/IPF: FVC values and HRCT findings for antifibrotic therapies (Ofev, pirfenidone)
Dalfampridine: objective ambulation measures (timed 25-foot walk, MSWS-12)
Benlysta: dates of prior immunosuppressive/concomitant standard therapy and response documentation for continuation (SLE/Lupus nephritis)
Dupilumab/Nucala/other biologics: reductions in exacerbations, steroid dose reductions, improved pulmonary function or eosinophil counts

Documentation Required

Specialist prescriber requirement

Many initial approvals require prescribing by or consultation with a specialist — oncologist, rheumatologist, pulmonologist, neurologist, geneticist, etc.

Actemra (RA, GCA, JIA): rheumatology consultation required
Arikayce (MAC lung disease): pulmonologist, infectious disease, or MAC specialist required
CFTR modulators (Kalydeco, Trikafta, Orkambi, Symdeko): prescribed by or in consultation with a CF specialist or pulmonologist
Oncology agents (many entries): prescribed by or in consultation with an oncologist; Part B/Part D determinations done at PA review

Billing Rule

Coverage duration & renewal

Authorizations commonly issued for 1 year or through end of plan year; some agents have shorter initial durations. Request renewals with documentation of continued benefit.

Camzyos: initial authorization 8 months (continuation 1 year)
Arikayce: authorization 1 year
Benlysta (SLE): initial 4 months, continuation 1 year

Denial Risk

Common denial risks

Denials likely when exclusion criteria or concurrent prohibited therapies are present, when required diagnostic testing is missing, or when Part B/Part D determinations are not addressed.

ESRD/Medicare Part D denial for certain cinacalcet uses (secondary hyperparathyroidism on dialysis) — submit under ESRD bundle instead
Concurrent prohibited therapies: concomitant biologic or JAK inhibitor use listed as exclusions for many biologics
Missing required diagnostic testing: e.g., lack of right-heart catheterization for PAH agents (Opsumit/Opsynvi/Treprostinil) or missing mutation testing for targeted oncology agents (BRAF, RET, MET, FGFR, etc.)
Failure to provide prior therapy history or specialist prescriber documentation for drugs with step or specialist requirements

Step Therapy

Step therapy / trial requirements

Many agents require prior trials of specified agents or classes (e.g., trials of TNF inhibitors, preferred adalimumab products, or specific chemotherapies). Document trial duration and outcome.

Actemra/RA: trial of Enbrel, a preferred adalimumab product (Hadlima/Simlandi), Rinvoq, or Xeljanz/XR (one of these) prior to initial approval
Rheumatology agents: many require 3-month trials of TNF inhibitors or other specified biologics per indication (see Rinvoq/Cimzia criteria)
Nexletol/Nexlizet (hyperlipidemia): requirements for trials of high-intensity statin (± ezetimibe) or statin intolerance prior to approval
Oncology (e.g., Lonsurf, Pemazyre, Blenrep, Blenrep combinations): require specified prior systemic regimens or lines of therapy

Clinical Evidence & Metrics

Evidence posture and documentation guidance: Approvals are tied to FDA‑approved indications and in many cases to specified "some medically-accepted/off‑label" uses; numerous indications require laboratory, imaging, or genetic/biomarker confirmation (examples: BRAF/RET/NRG1/EGFR/IDH/FGFR2/FLT3/KRAS/BRCA/CFTR testing, right‑heart catheterization for PAH, functional C1‑INH and C4 for HAE).

Required diagnostic tests are explicitly specified by drug/indication (eg, CLAUDIN 18.2 positivity ≥75% IHC, TmP/GFR and serum phosphorus for Crysvita).

Continuation authorizations commonly require prescriber attestation of clinical response (not necessarily replicating numeric utilization metrics), and metric_cards or other UI elements need not duplicate the policy's stats_bar — do not duplicate metrics where not required.

Populators should include direct links to primary FDA labeling or guideline sources (eg, FDA prescribing information, AASLD/IDSA guidance for HCV agents) when available to support the documented test thresholds and biomarker definitions.

Background

This file is one segment (part X of 17) of the overall multi-part PA policy.

Selected definitions

Authorization duration (Authorization duration)Length of time approval is granted (examples in policy: commonly 1 year; some initial durations shorter - e.g., 4 months, 6 months, 8 months)

Concurrent use exclusion (Concurrent use exclusion)Policy disallows simultaneous use of the listed drug with specified other agents (e.g., concurrent biologic DMARDs, other monoclonal antibodies, CGRP inhibitors, JAK inhibitors) as noted per product

Part B prerequisite (Part B prerequisite)Indicates whether a Part B coverage determination or prerequisite applies; many oncology/specialty agents note Part B vs Part D will be determined at prior authorization review

Prerequisite therapy required (Prerequisite Therapy Required)Indicates required prior trials/step therapy before approval (many agents require prior trial(s) of specified drugs/classes)

Man/Woman operational definition (Man/Woman)Defined as individual with the biological traits of a man or woman, regardless of gender identity — used for sex-specific criteria

Revision History

2026-03-24Last reviewLatest

Policy part reviewed; effective date 2026-04-01; no material changes recorded in this part.

Policy Summary

PayerCareSource

PolicyMultiple drug-specific prior authorization criteria (Part 1 of 17)

Policy CodePolicy H6396_OH-SNP-M-4313298-V.5_C

Change TypeNo material change

Effective DateApr 1, 2026

Next Review Date

Key ActionThese drugs require prior authorization; submit diagnosis, concurrent medications, previous drug trials and relevant lab/imaging/genetic tests per drug-specific criteria.

SourceLink

On This Page

Interstitial lung disease associated with systemic sclerosis: age ≥ 18 years (initial and continuation).

Prescriber restriction (initial therapy): prescribed by or in consultation with a rheumatologist for RA/GCA/PJIA/SJIA; for lung disease prescribe by or in consultation with a pulmonologist or rheumatologist (initial and continuation).

Coverage duration: approve through end of plan year.

Initial therapy - indication specific prior-treatment rules

Rheumatoid arthritis (RA) initial: ONE of the following prior trials: etanercept (Enbrel), a preferred adalimumab product (e.g., Hadlima/Simlandi), upadacitinib (Rinvoq) or tofacitinib/XR (Xeljanz/XR). Trials with certolizumab (Cimzia), infliximab, sarilumab (Kevzara), golimumab SC/IV, non‑preferred adalimumab products, or abatacept (Orencia) may also count.
Polyarticular juvenile idiopathic arthritis (PJIA) initial: ONE of the following prior trials: etanercept (Enbrel), upadacitinib (Rinvoq), tofacitinib (Xeljanz) or a preferred adalimumab product; trials with sarilumab (Kevzara), infliximab, abatacept (Orencia), or non‑preferred adalimumab product may also count.
Systemic‑onset JIA (SJIA): approve (initial).
Giant cell arteritis (GCA): patient has tried or is currently taking a systemic corticosteroid, or systemic corticosteroid is contraindicated.
Interstitial lung disease associated with systemic sclerosis: A) elevated acute phase reactants, and B) diagnosis confirmed by high‑resolution computed tomography (HRCT).

Continuation: approve if patient had a response to therapy as determined by the prescriber (all indications).

Coverage duration: 1 year.

Ankylosing spondylitis (AS), psoriatic arthritis (PsA), rheumatoid arthritis (RA), plaque psoriasis (PP), pyoderma gangrenosum, sarcoidosis, scleritis, sterile corneal ulceration, non‑radiographic axial spondyloarthritis: age ≥ 18 years (initial therapy).

Juvenile idiopathic arthritis (JIA)/uveitis/Behçet's disease: age ≥ 2 years (initial therapy).

Hidradenitis suppurativa (HS): age ≥ 12 years (initial therapy).

Prescriber restrictions (initial therapy): prescribed by or in consultation with an appropriate specialist based on indication (examples: rheumatologist for RA/JIA/AS/nr‑axSpA; dermatologist for PsA/PP/HS/pyoderma gangrenosum; gastroenterologist for UC/CD; ophthalmologist for uveitis/scleritis).

Coverage duration: approve through end of plan year.

Indication‑specific initial therapy requirements (representative examples)

Crohn's disease (CD): initial therapy — approve (no additional prior biologic required per policy summary).
Juvenile idiopathic arthritis (JIA)/JRA: must meet one of the following: A) tried one other systemic therapy (e.g., methotrexate, sulfasalazine, leflunomide, NSAID); B) tried a biologic (e.g., etanercept, abatacept, infliximab, anakinra, tocilizumab); C) will be starting adalimumab concurrently with methotrexate, sulfasalazine, or leflunomide; D) absolute contraindication to methotrexate/sulfasalazine/leflunomide; or E) aggressive disease.
Hidradenitis suppurativa (HS): tried one other therapy (e.g., intralesional or oral corticosteroid, systemic antibiotics, isotretinoin).
Plaque psoriasis (PP): either A) tried at least one traditional systemic agent (e.g., methotrexate, cyclosporine, acitretin, PUVA) for ≥ 3 months unless intolerant (a prior biologic trial may count), or B) contraindication to methotrexate.
Rheumatoid arthritis (RA): tried one conventional synthetic DMARD for ≥ 3 months (a 3‑month biologic trial may also count).
Ulcerative colitis (UC): initial therapy — approve (per policy summary).
Behçet's disease: tried one conventional therapy (e.g., systemic corticosteroid, azathioprine, methotrexate, cyclosporine, chlorambucil, cyclophosphamide, interferon alfa) OR has ophthalmic manifestations.
Sarcoidosis: tried one corticosteroid AND one immunosuppressant (e.g., methotrexate, mycophenolate mofetil, chlorambucil, thalidomide, infliximab, chloroquine).

Continuation: approve if patient had a response to therapy as determined by the prescriber (all indications).

Initial authorization length: 4 months for atopic dermatitis. Continuation criteria (not included here) require clinical response after the initial period.

Atopic dermatitis and some biologics: may require age ≥ 12 years or older depending on agent.

Adult rheumatologic, dermatologic, or gastroenterologic indications: typically age ≥ 18 years for initial therapy.

Typical induction / prior therapy requirements: many agents require documented trial(s) of conventional systemic agents (e.g., methotrexate, sulfasalazine, leflunomide), a TNF inhibitor, or other indicated prior biologic(s) as specified by indication. Examples of agents following this structure include: CIMZIA (certolizumab pegol), ENBREL (etanercept), COSENTYX (secukinumab), DUPIXENT (dupilumab) — verify indication‑specific prior therapy rules for each product.

Provider note / step‑therapy: ensure documentation of prior therapies and reason for discontinuation (lack of efficacy, intolerance, or contraindication) to support exceptions to step requirements.