Cigna inflammatory conditions policy update Prior Auth

Coverage Criteria and Indication-Specific Rules

Step therapy (Initial and escalation steps)

Covered when the step therapy and prior authorization requirements below are met

Step 1 Preferred Agents: Step 1 lists preferred agents by rheumatology indication (examples: RA and JIA: Enbrel and adalimumab products; AS: Enbrel, adalimumab products, Taltz; nr-axSpA: Cimzia, Taltz; PsA: Enbrel, adalimumab products, Otezla, Skyrizi SC, ustekinumab SC products)

See policy Step 1 mapping for full lists

Step 2a Non-Preferred (directed to ONE Step 1 Product): Non-preferred Step 2a products require a trial directed to a specific Step 1 product (examples: tocilizumab SC directed to adalimumab; Rinvoq/Xeljanz directed to Enbrel or an adalimumab product; other directed mappings per indication)

See policy Step 2a directed mappings

Step 2b and Step 3a: Step 2b lists certain non-preferred agents (e.g., Bimzelx). Step 3a non-preferred products require trials directed to TWO Step 1 or 2a products and documentation is required for approval (examples include Cimzia, Kevzara, Kineret, Olumiant, Orencia SC, Simponi SC, Cosentyx SC)

See policy Step 2b/3a mapping and documentation requirements

Non-Preferred Product Exception Criteria (examples shown for Cimzia)

Non-preferred product (example: Cimzia) is covered as medically necessary when the exception criteria below are met for the specific indication.

Rheumatoid Arthritis - Initial Therapy

Criterion i: Patient meets the standard Inflammatory Conditions - Cimzia Prior Authorization Policy criteria
Criterion ii: Patient has tried TWO of: a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR (documentation required)TWO products
Trials of multiple products in same product family count as ONE product

Ankylosing Spondylitis - Initial Therapy

Criterion i:

Exception and approval criteria by product and indication

Exception approval for non-preferred products when specific prior therapy or established-use conditions are met

Crohn's Disease - Cimzia initial/exception: Patient has Crohn's Disease AND has tried ONE of an adalimumab product, Omvoh SC, Skyrizi SC (on-body injector), an ustekinumab SC product, Tremfya SC, or Zymfentra; OR a trial of an infliximab IV product or listed IV formulations counts; OR patient has been established on Cimzia for ≥90 days with claims verification (90-day supply in past 130 days) or prescriber verification

Examples of adalimumab and ustekinumab products enumerated in policy

Simponi Subcutaneous - Initial Therapy: Approve for 6 months if patient meets standard Simponi Subcutaneous prior authorization criteria AND has tried TWO of listed agents (varies by indication) with documentation required6 months

If criteria not met, offer review for Step 1/2 products per standard policies

Ulcerative Colitis - Simponi initial: Approve for 6 months if patient meets standard Simponi Subcutaneous prior authorization criteria AND has tried ONE of an adalimumab product, Omvoh SC, Skyrizi SC (on-body injector), an ustekinumab SC product, Tremfya SC, Velsipity, or Zymfentra

Tocilizumab subcutaneous — Polyarticular JIA or Rheumatoid Arthritis (patient currently receiving)

Approve for 1 year if BOTH of the following are met:

TOC-Current-1: i. Patient meets the standard Inflammatory Conditions - Tocilizumab Subcutaneous Policy criteria

standard policy referenced

TOC-Current-2: ii. Patient meets ONE of: (a) PJIA and tried one adalimumab product (Enbrel, Cimzia, infliximab product, or Simponi Aria may count); (b) RA and tried one adalimumab product (Cimzia, Enbrel, infliximab or Simponi may count); (c) prescriber reports heart failure or previously treated lymphoproliferative disorder; (d) established on IV tocilizumab ≥90 days; (e) established on SC tocilizumab ≥90 days with claims showing ≥90-day supply dispensed within past 130 days or prescriber attestation if claims unavailable

Claims verification required for (e); prescriber verification allowed if claims unavailable

Sarilumab (Kevzara) — Rheumatoid Arthritis initial therapy

Approve for 6 months if BOTH of the following are met:

KEV-Init-1: i. Patient meets the standard Inflammatory Conditions - Kevzara Prior Authorization Policy criteria

standard policy referenced

KEV-Init-2: ii. Patient meets ONE of: (a) patient has tried TWO of: a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR (documentation required) [multiple products in same molecule count as ONE]; (b) prescriber reports heart failure or previously treated lymphoproliferative disorder

Documentation required for prior trials

Kevzara — Juvenile Idiopathic Arthritis / Juvenile Rheumatoid Arthritis initial and continuation

Initial: Approve for 6 months if BOTH met; Continuation: Approve 1 year if BOTH met for patients currently receiving

KEV-JIA-Init-1: i. Patient meets the standard Inflammatory Conditions - Kevzara Prior Authorization Policy criteria

KEV-JIA-Init-2: ii. ONE of: (a) patient tried TWO of: tocilizumab SC product, Enbrel, adalimumab product, Rinvoq/Rinvoq LQ, or Xeljanz (documentation required); (b) prescriber reports heart failure, previously treated lymphoproliferative disorder, previous serious infection, or demyelinating disorder

Documentation required for prior trials

KEV-JIA-Cont-1: For patients currently receiving Kevzara: i. meets standard Kevzara policy; AND ii. ONE of: (a) RA and tried TWO of adalimumab product, Rinvoq, or Xeljanz/XR; (b) JIA and tried TWO of tocilizumab SC product, Enbrel, adalimumab product, Rinvoq/Rinvoq LQ, or Xeljanz; (c) prescriber reports heart failure or previously treated lymphoproliferative disorder; (d) established on Kevzara ≥90 days with claims verification of ≥90-day supply within past 130 days or prescriber attestation if claims unavailable

Claims verification required for (d); prescriber verification allowed if claims unavailable

Bimzelx (risankizumab) — multiple indications and continuation

Initial approvals vary by indication (3–6 months) if BOTH product-specific standard PA criteria and prior therapy criteria are met; continuation approvals for patients currently receiving approved for 1 year if criteria met.

BIM-Gen-Std: Patient meets the standard Inflammatory Conditions - Bimzelx Prior Authorization Policy criteria

standard policy referenced

BIM-AS-Init-2: Ankylosing Spondylitis initial: patient has tried one of Enbrel, an adalimumab product, or Taltz

Documentation of prior trial required per policy

BIM-HS-Init-2: Hidradenitis Suppurativa initial: patient has tried one of an adalimumab product or Cosentyx SC

BIM-nrax-Init-2: nr-axSpA initial: patient has tried one of Cimzia or Taltz (trials of Enbrel, adalimumab products, infliximab, or Simponi also count)

Cosentyx SC — Ankylosing spondylitis initial therapy (partial)

Approve for 6 months if BOTH are met:

COS-Init-1: i. Patient meets the standard Inflammatory Conditions - Cosentyx Subcutaneous Prior Authorization Policy criteria

standard policy referenced

COS-Init-2: ii. Patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR (documentation required)

Multiple products of same molecule count as one trial; trials of Cimzia, infliximab, or Simponi may also count

Ankylosing Spondylitis - Initial Therapy (Cosentyx example)

Approve for 6 months when BOTH of the following are met:

Ankylosing Spondylitis initial therapy: (i) Patient meets the standard Inflammatory Conditions - Cosentyx Subcutaneous Prior Authorization Policy criteria; AND (ii) Patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR (documentation required)

Trials of multiple adalimumab products count as one product; trials of Xeljanz products count collectively as one product; trials of Cimzia, infliximab, or Simponi may also count as TNFi trial.

nr-axSpA - Initial Therapy (Cosentyx example)

Approve for 6 months when BOTH of the following are met:

nr-axSpA initial therapy: (i) Patient meets the standard Inflammatory Conditions - Cosentyx Subcutaneous Prior Authorization Policy criteria; AND (ii) Patient has tried TWO of Cimzia, Taltz, or Rinvoq (documentation required)

Trials of other TNFis or infliximab products may count per notes; multiple adalimumab products count as one product.

Plaque Psoriasis - Initial Therapy (Cosentyx example & others)

Approve for 3 months when BOTH of the following are met:

Plaque psoriasis initial therapy: (i) Patient meets the standard Inflammatory Conditions - Cosentyx (or relevant product) Prior Authorization Policy criteria; AND (ii) Patient has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi SC, Sotyktu, an ustekinumab SC product, Taltz, or Tremfya SC (documentation required)

Adalimumab and ustekinumab product groups count as one trial when multiple products of that group were used.

Psoriatic Arthritis - Initial Therapy

Approve for 6 months when BOTH of the following are met:

Psoriatic arthritis initial therapy adults: (i) Patient meets the standard Inflammatory Conditions - Cosentyx Prior Authorization Policy criteria; AND (ii) Patient is ≥18 years and has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi SC, an ustekinumab SC product, Taltz, Tremfya SC, or Xeljanz/XR (documentation required)

For patients <18 years, requirement is one prior agent from a specified list; multiple product trials within same class count as one.

Continuation for patients currently receiving Cosentyx (SC or IV)

Approve for 1 year when BOTH of the following are met:

Cosentyx continuation: (i) Patient meets the standard Inflammatory Conditions - Cosentyx SC Prior Authorization Policy criteria; AND (ii) Patient meets one of specified prior-therapy history conditions (e.g., prior trials per indication) OR has been established on Cosentyx IV ≥90 days OR established on Cosentyx SC ≥90 days with claims showing a 90-day supply dispensed within past 130 days or prescriber verification if claims not available

Exceptions allowed when claims history unavailable but prescriber verifies ≥90 days of paid claims therapy.

Siliq - Plaque Psoriasis initial and continuation

Initial: Approve for 3 months when BOTH met; Continuation: Approve for 1 year when BOTH met

Siliq initial: (i) Patient meets the standard Inflammatory Conditions - Siliq Prior Authorization Policy criteria; AND (ii) Patient has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi SC, Sotyktu, an ustekinumab SC product, Taltz, or Tremfya SC (documentation required)

If criterion (ii) not met, offer review for Preferred Products per policy.

Siliq continuation: (i) Patient meets the standard Inflammatory Conditions - Siliq Prior Authorization Policy criteria; AND (ii) Patient has tried TWO of listed alternatives OR has been established on Siliq ≥90 days with claims evidence of 90-day supply dispensed in past 130 days or prescriber verification if claims unavailable.

Prescriber verification allowed when claims unavailable

Ilumya (and other IL-23 blockers) - Plaque Psoriasis initial and continuation

Initial: Approve for 3 months when BOTH met; Continuation: Approve for 1 year when BOTH met

Ilumya initial: (i) Patient meets the standard Inflammatory Conditions - Ilumya Prior Authorization Policy criteria; AND (ii) Patient has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi SC, Sotyktu, an ustekinumab SC product, Taltz, or Tremfya SC (documentation required)

If prior trials not met, offer review for Preferred Products per policy.

Ilumya continuation: (i) Patient meets the standard Inflammatory Conditions - Ilumya Prior Authorization Policy criteria; AND (ii) Patient has tried TWO of listed alternatives OR has been established on Ilumya ≥90 days with claims evidence of 90-day supply dispensed in past 130 days or prescriber verification if claims unavailable.

Claims verification exception allowed with prescriber confirmation of paid claims therapy.

Taltz and other products - All Conditions

General coverage stance

Taltz coverage: Approve Taltz (initial therapy for a duration as directed or 1 year for continuation) if patient meets the standard Inflammatory Conditions - Taltz Prior Authorization Policy criteria

Applies to Taltz across indicated inflammatory conditions per its standard policy

Entyvio Subcutaneous - Crohn's Disease (Initial)

Approve Entyvio subcutaneous for 6 months if ALL of the following are met:

Entyvio Crohn's initial: Patient meets the standard Inflammatory Conditions - Entyvio Subcutaneous Prior Authorization Policy criteria

standard policy referenced

Additional requirement: Patient meets ONE of: (a) tried TWO of an adalimumab product, Omvoh SC, Skyrizi SC, Tremfya SC, an ustekinumab SC product, Zymfentra, Cimzia, or Rinvoq (documentation required); OR (b) prescriber indicates patient has started or is undergoing induction therapy with Entyvio IV

Documentation required for prior trials

Entyvio Subcutaneous - Ulcerative Colitis (Initial)

Approve Entyvio subcutaneous for 6 months if ALL of the following are met:

Entyvio UC initial: Patient meets the standard Inflammatory Conditions - Entyvio Subcutaneous Prior Authorization Policy criteria

standard policy referenced

Additional requirement: Patient meets ONE of: (a) tried TWO of an adalimumab product, Skyrizi SC, an ustekinumab SC product, Zymfentra, Omvoh SC, Rinvoq, Simponi SC, Tremfya SC, Velsipity, or Xeljanz/XR (documentation required); OR (b) prescriber indicates patient has started or is undergoing induction therapy with Entyvio IV

Documentation required for prior trials

Entyvio Subcutaneous - Continuing therapy

Approve Entyvio SC for 1 year if ALL of the following are met:

Standard criteria: Patient meets the standard Inflammatory Conditions - Entyvio Subcutaneous Prior Authorization Policy criteria

standard policy referenced

Additional requirement: Patient meets ONE of: (a) prior trials as specified by disease with documentation; (b) established on Entyvio IV ≥90 days per prescriber; OR (c) established on Entyvio SC ≥90 days with claims showing 90-day supply in past 130 days (prescriber verification acceptable if claims unavailable)

Claims verification required when applicable

Ilumya - Established therapy and alternative review

Approve Ilumya if ALL of the following are met (initial or continuing per document):

Ilumya established: Patient has been established on Ilumya for at least 90 days and prescription claims history indicates at least a 90-day supply dispensed within past 130 days, or if claims not available, prescriber verification that patient has been receiving Ilumya for at least 90 days

Claims verification window: 90-day supply within prior 130 days

Alternate review if criterion not met: If established-use criterion is not met, offer to review for a Preferred Product using the respective standard Inflammatory Conditions prior authorization criteria

Preferred product lists provided in policy

Kineret - Rheumatoid Arthritis

Kineret (an IL-1 blocker) approval rules:

Kineret RA initial: Approve for 6 months if ALL: patient meets standard Kineret Prior Authorization Policy criteria; AND patient has tried TWO of a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR (documentation required)

Documentation of prior trials required per policy

Kineret continuing: Approve for 1 year if ALL: patient meets standard Kineret criteria; AND patient meets ONE of: (a) prior trials of TWO listed agents; OR (b) patient established on Kineret ≥90 days with prescription claims showing 90-day supply in past 130 days or prescriber verification

Claims verification required when applicable

Orencia Subcutaneous - Multiple indications

Orencia SC approval rules across indications (RA, JIA/JRA, Psoriatic Arthritis):

Orencia RA initial: Approve for 6 months if ALL: patient meets standard Orencia SC prior authorization criteria; AND patient meets ONE of: (a) patient has tried TWO of a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR (documentation required); OR (b) prescriber documents specific comorbidities (heart failure, treated lymphoproliferative disorder, prior serious infection, or demyelinating disorder)

Documentation required for prior trials

Orencia JIA/JRA initial: Approve for 6 months if ALL: patient meets standard Orencia SC criteria for JIA/JRA; AND ONE of: (a) patient has tried TWO of listed agents (tocilizumab SC, Enbrel, adalimumab, Rinvoq/Rinvoq LQ, or Xeljanz) with documentation; OR (b) prescriber documents listed comorbidities

Documentation required

Orencia PsA initial: Approve for 6 months if ALL: patient meets standard Orencia SC criteria for psoriatic arthritis; AND patient is ≥18 and has tried TWO of listed agents (Enbrel, adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi SC, ustekinumab SC, Taltz, Tremfya SC, or Xeljanz/XR) OR pediatric criteria for <18 with one prior trial as listed

Psoriatic Arthritis - Initial Therapy

Approve for 6 months if ALL of the following are met

Orencia Psoriatic Arthritis initial

Prior therapy or contraindication: a) ≥18 and tried TWO of listed products; OR b) <18 and tried ONE of listed products; OR c) prescriber reports heart failure, prior lymphoproliferative disorder, prior serious infection, or demyelinating disorder
Multiple products in same class count as one trial

Orencia - Patient Currently Receiving

Approve for 1 year if ALL of the following are met

Orencia continuation: Patient meets the standard Inflammatory Conditions - Orencia Subcutaneous Policy criteria

AND patient meets ONE of criteria a-g (e.g., prior trials, established IV ≥90 days, prescriber-reported comorbidity, or established SC ≥90 days with claims verification)

Olumiant - Rheumatoid Arthritis

Approve for 6 months (initial) or 1 year (currently receiving) if ALL of the following are met

Olumiant initial: Patient meets the standard Inflammatory Conditions - Olumiant Prior Authorization Policy criteria

AND patient has tried TWO of tocilizumab SC, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR

Olumiant continuation: Patient meets the standard Inflammatory Conditions - Olumiant Prior Authorization Policy criteria

AND patient meets ONE of: tried TWO of listed agents OR established on Olumiant ≥90 days with claims verification

Rinvoq / Rinvoq LQ - Initial Therapy by condition

Approve for 6 months for initial therapy when ALL of the following are met

Ankylosing spondylitis initial: Patient meets the standard Inflammatory Conditions - Rinvoq/LQ Prior Authorization Policy criteria AND has tried one of Enbrel or an adalimumab product6 months

Documentation/examples of adalimumab products provided

Crohn's disease initial: Patient meets the standard Rinvoq/LQ criteria AND has tried one adalimumab product (infliximab or Cimzia may count)6 months

Juvenile idiopathic arthritis initial: Patient meets the standard Rinvoq/LQ criteria AND has tried one of Enbrel or an adalimumab product6 months

Rinvoq - Patient Currently Receiving

Approve for 1 year if ALL of the following are met

Rinvoq continuation: Patient meets the standard Inflammatory Conditions - Rinvoq/LQ Prior Authorization Policy criteria1 year

AND patient meets ONE of condition-specific prior trial requirements (e.g., RA: tried Enbrel or an adalimumab product; Crohn's: tried an adalimumab product; nr-axSpA: tried Cimzia; etc.)

Initial Therapy

Covered when the following indication-specific criteria are met (examples extracted):

Initial therapy for several indications: Patient meets the standard Inflammatory Conditions - [Drug] Prior Authorization Policy criteria AND patient has tried one of Enbrel or an adalimumab product (or other specified biologic depending on indication, e.g., Cimzia, infliximab products, Simponi).6 months approval typical

Applies to ankylosing spondylitis, rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ulcerative colitis per policy

Patient Currently Receiving / Continuation

Continuation therapy (patient currently receiving):

Continuation therapy: Patient meets the standard Inflammatory Conditions - [Drug] Prior Authorization Policy criteria AND patient meets ONE of: prior trial of specified biologic(s) for the indication OR patient has been established on the drug for at least 90 days with prescription claims showing a 90-day supply within the last 130 days (or prescriber verification).1 year approval typical

Includes Rinvoq, Rinvoq LQ, Xeljanz/XR, and related agents as described in policy

Step/Preferred Product Pathway

Alternative product review when prior-trial requirement not met:

Offer review for Preferred/Step products: If the patient has met the standard Inflammatory Conditions - [Drug] criteria but has not met the prior-biologic trial requirement, offer to review for specified Preferred or Step products (examples include Enbrel, adalimumab biosimilars, Cyltezo, Simlandi, Otezla, Skyrizi, Stelara, Tremfya, Taltz, Velsipity, Zymfentra) using their respective Prior Authorization criteria.

Lists vary by indication per policy

Other Conditions

Other conditions / general statement:

Other indications: Approve drug (initial therapy for duration as directed or 1 year for continuation) if patient meets the standard Inflammatory Conditions - [Drug] Prior Authorization Policy criteria.

Generic statement appears across multiple agents in policy

Xeljanz/XR — Juvenile Idiopathic Arthritis (Initial and Continuation)

Covered when ALL of the following are met

JIA Initial Therapy Xeljanz: Approve for 6 months if BOTH: (i) patient meets the standard Inflammatory Conditions - Xeljanz/XR Prior Authorization Policy criteria; AND (ii) patient has tried one of Enbrel or an adalimumab product (a trial of Cimzia, an infliximab product, or Simponi Aria may also count)

Examples of adalimumab products enumerated in policy

JIA - Currently Receiving Xeljanz: Approve for 1 year if BOTH: (i) patient meets the standard Inflammatory Conditions - Xeljanz/XR Prior Authorization Policy criteria; AND (ii) patient meets ONE of: (a) has JIA and tried Enbrel or an adalimumab product; OR (b) has been established on Xeljanz ≥90 days with prescription claims showing a 90-day supply within past 130 days (verification required) or prescriber verification if claims unavailable90 days; 130 days claims window

Exception allowed when claims file unavailable if prescriber verifies at least 90 days and paid claims exist

Other targeted small molecules and oral agents

Covered when the referenced standard prior authorization policy criteria for each agent and indication are met

Other agents (examples): Approve Otezla, Velsipity, Zeposia, Sotyktu, and similar targeted small molecules/oral agents if the patient meets the respective standard Prior Authorization Policy criteria for that agent and indication

Refer to each agent's standard prior authorization policy for specific criteria and durations

This Coverage Policy applies to Cigna‑administered benefit plans. When a conflict exists between this Coverage Policy and a customer's specific benefit plan document, the customer's benefit plan document supersedes the Coverage Policy. Coverage determinations must consider the applicable benefit plan terms, any laws or regulations, relevant collateral materials (including Coverage Policies), and the facts of the individual case; medical directors retain clinical discretion in individual determinations.

The policy defines specific exception criteria for non‑preferred products. Any exception not specifically listed in the Inflammatory Conditions Preferred Specialty Management Policy is considered not medically necessary and will not be approved under this policy.

When a request for a non‑preferred product does not meet the product‑specific exception criteria, the reviewer should offer to review alternative Step 1 or Step 2 Preferred Products using the respective standard Inflammatory Conditions prior authorization policy criteria. Lists of Step 1/Step 2 preferred alternatives are provided by indication and should be evaluated under their standard prior authorization requirements.

Continuation approvals require verification of prior dispensing. If prescription claims history cannot confirm the required dispensing (for example, evidence of a 90‑day supply within the prior 130 days) and the prescriber cannot attest to paid claims use, the continuation criteria are not met and approval for continued therapy may be denied.

Requests that fail to meet the standard Inflammatory Conditions prior authorization criteria for the specific product or lack required prior‑therapy documentation are effectively excluded from approval under the product's exception criteria. In such cases the policy directs offering review for alternative Preferred/Step products; requests not meeting the standard prior authorization or prior‑therapy criteria are not approved under the listed indication criteria.

Within the provided document excerpts there are no additional explicit exclusions beyond the condition‑specific criteria and the alternative product pathways. The policy uses per‑product and per‑indication criteria and routes unmet requests to preferred product review rather than listing further standalone exclusions.

Rather than listing discrete additional exclusions, the policy provides alternate product review and step‑therapy pathways when specific prior‑therapy criteria are not satisfied. Alternate product review/step therapy routing is the mechanism used instead of explicit extra exclusions in these sections.

Verification of prior paid claims is required for many continuation rules. Patients who have been receiving therapy only via samples, coupons, or other non‑paid means do not meet the paid‑claims requirement; samples or coupons do not satisfy the prescription claims requirement for continuation verification unless the prescriber can verify paid claims use.

The policy tables and footnotes indicate approved agent/indication mappings. Where a table shows "--" for a drug/indication combination, that formulation or agent is not approved for that targeted indication under these mappings.

Entries marked with "--" denote that the agent/indication combination is not indicated or approved per the mapping tables in this policy; such combinations are not covered for that targeted indication according to the tables.

Reimbursement will not be provided for services billed for diagnoses or conditions that are not covered by this Coverage Policy. Claims submitted without a covered diagnosis or procedure code under the applicable Coverage Policy will be denied as not covered.

Non‑preferred products that do not satisfy the specified non‑preferred product exception criteria are considered not medically necessary and may be denied; approval of non‑preferred agents is contingent on meeting the documented exception conditions.

When listed criteria for a requested non‑preferred product are not met, the policy instructs reviewers to offer evaluation of alternative preferred products. In other words, the criteria direct review toward alternative products rather than approving the requested agent when exception requirements are unmet.

Coding and Verification Parameters

Tumor Necrosis Factor Inhibitorsmixed

adalimumab-adbm	adalimumab-adbm subcutaneous injection (Boehringer Ingelheim)
adalimumab-adaz	adalimumab-adaz subcutaneous injection (Sandoz/Novartis)
adalimumab-ryvk	adalimumab-ryvk subcutaneous injection (Alvotech/Teva)
Cyltezo	Cyltezo (adalimumab-adbm subcutaneous injection -Boehringer Ingelheim)
Simlandi	Simlandi (adalimumab-ryvk subcutaneous injection -Alvotech/Teva)
Cimzia	Cimzia (certolizumab pegol subcutaneous injection -UCB)
Enbrel	Enbrel (etanercept subcutaneous injection -Amgen)
Simponi	Simponi (golimumab subcutaneous injection -Janssen Biotech/Johnson & Johnson)
Zymfentra	Zymfentra (infliximab-dyyb subcutaneous injection -Celltrion)

Interleukin-6 Blockersmixed

Actemra	Actemra (tocilizumab subcutaneous injection -Genentech/Roche)
Tyenne	Tyenne (tocilizumab-aazg subcutaneous injection -Fresenius Kabi)
Kevzara	Kevzara (sarilumab subcutaneous injection -Regeneron)

Interleukin-17 Blockersmixed

Bimzelx	Bimzelx (bimekizumab subcutaneous injection -UCB)
Cosentyx	Cosentyx (secukinumab subcutaneous injection -Novartis)
Siliq	Siliq (brodalumab subcutaneous injection -Valeant)
Taltz	Taltz (ixekizumab subcutaneous injection -Eli Lilly)

Interleukin-23 Blockersmixed

Ilumya	Ilumya (tildrakizumab-asmn subcutaneous injection -Sun/Merck)
Omvoh	Omvoh (mirakizumab-mrkz subcutaneous injection -Eli Lilly)
Skyrizi	Skyrizi (risankizumab-rzaa subcutaneous injection -AbbVie)
Tremfya	Tremfya (guselkumab subcutaneous injection -Janssen/Johnson & Johnson)

Interleukin 12/23 Blocker (Ustekinumab products)mixed

Stelara	Stelara (ustekinumab subcutaneous injection -Janssen Biotech/Johnson & Johnson)
Imuldosa	Imuldosa (ustekinumab-srlf subcutaneous injection -Accord BioPharma)
Selarsdi	Selarsdi (ustekinumab-aekn subcutaneous injection -Alvotech/Teva)
ustekinumab-ttwe	ustekinumab-ttwe subcutaneous injection (Quallent)
Yesintek	Yesintek (ustekinumab-kfce subcutaneous injection -Biocon)

Other targeted agentsmixed

Kineret	Kineret (anakinra subcutaneous injection -Swedish Orphan Biovitrim)
Orencia	Orencia (abatacept subcutaneous injection -Bristol Myers Squibb)
Entyvio	Entyvio (vedolizumab subcutaneous injection -Takeda)
Olumiant	Olumiant (baricitinib tablets -Eli Lilly)
Rinvoq	Rinvoq (upadacitinib extended-release tablets -AbbVie)
Xeljanz	Xeljanz (tofacitinib tablets, tofacitinib oral solution -Pfizer)
Otezla	Otezla (apremilast tablets -Amgen)
Velsipity	Velsipity (etrasimod tablets -Pfizer)

No codes listed in this document portionmixed

No codes listed

Products referencedmixed

Olumiant	Olumiant (baricitinib) — JAK inhibitor
Actemra subcutaneous	Tocilizumab subcutaneous
Tyenne subcutaneous	Tocilizumab subcutaneous (alternative brand)
Orencia subcutaneous	Abatacept subcutaneous
Orencia intravenous	Abatacept intravenous
Rinvoq	Upadacitinib
Rinvoq LQ	Low-quantity or alternate formulation of upadacitinib

Referenced agents with prior authorization linkagemixed

Xeljanz/XR	JAK inhibitor — referenced prior authorization policy for multiple inflammatory conditions (includes oral solution)
Otezla	Phosphodiesterase Type 4 inhibitor — All Conditions (requires standard Otezla prior authorization criteria)
Velsipity	Sphingosine 1-Phosphate Receptor Modulator — All Conditions (refer to Velsipity prior authorization policy)
Zeposia	Sphingosine 1-Phosphate Receptor Modulator — Approve if meets Multiple Sclerosis and Ulcerative Colitis prior authorization criteria
Sotyktu	Tyrosine Kinase 2 Inhibitor — All Conditions (refer to Sotyktu prior authorization policy)

Table 1 and Table 2 listed agentsmixed

Cimzia	TNFi — indicated across multiple rheumatology and gastroenterology indications (per Table 1)
Enbrel	TNFi — indicated across multiple rheumatology and dermatology indications (per Table 1)
Adalimumab products	Adalimumab (Humira and biosimilars) — multiple indications including CD and UC
Infliximab intravenous products	Infliximab IV — multiple indications including CD and UC
Zymfentra	TNFi — indicated for Crohn's disease and ulcerative colitis (maintenance dosing only note applies)
Simponi Subcutaneous / Simponi Aria	TNFi — indicated for selected rheumatology and gastroenterology indications as listed in Table 1
Bimzelx	Interleukin-17 blocker — indicated for rheumatology and dermatology indications (per Table 2)
Cosentyx Subcutaneous	Interleukin-17 blocker — indicated for rheumatology and dermatology indications (per Table 2)

Continuation verification look-back

Look-back requirementClaims history must include at least 130 days to verify the patient received 90 or 120 days of the Non-Preferred product within a 130‑day look‑back; if 130 days of claims are unavailable, prescriber verification is acceptable provided therapy was via paid claims (no samples/coupons)

Claims verification optionIf ≥130 days of claims exist, claims must demonstrate the required 90/120 days of use within the 130‑day window

Prescriber verification optionWhen 130 days of claims are unavailable, prescriber must verify ≥90/120 days of therapy and that therapy was received via paid claims (not samples/coupons)

Provider Requirements, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required (per standard policies)

Prior authorization is required and governed by the referenced standard Inflammatory Conditions prior authorization policies for the specific product and indication. Providers must follow the applicable standard PA policy referenced for the requested agent and indication; coverage decisions are contingent on meeting those agent- and indication-specific PA criteria.

Prior authorization required for initiation and continuation of therapies per the applicable standard Prior Authorization Policy for the product/indication.
Non-Preferred products require a product-specific exception and will be approved only when the non-preferred product exception criteria are met (see Non-Preferred Product Exception Criteria).
If referenced standard PA criteria are not met, the request may be denied as not medically necessary.
Providers should refer to the selected standard Inflammatory Conditions Prior Authorization Policy tables for agent–indication mapping and allowed indications.

Prior Authorization

Approval Duration and Requirement Summary

Background and Policy Context

Multiple biologic and targeted small‑molecule therapies are available to treat inflammatory conditions including rheumatoid arthritis, ankylosing spondylitis, juvenile idiopathic arthritis, psoriatic arthritis, plaque psoriasis, Crohn's disease, and ulcerative colitis. The policy maps approved agents to indications and references product‑specific prior authorization policies for detailed medical necessity criteria.

Definitions and Abbreviations

RARheumatoid arthritis (abbreviation RA used in policy)

Usage contextAbbreviation appears in tables mapping agents to rheumatology indications

Reference to standard policiesRefer to selected standard Inflammatory Conditions Prior Authorization Policies for indication‑specific criteria

JIA / PJIA

JIA / PJIAJuvenile idiopathic arthritis / Polyarticular juvenile idiopathic arthritis (abbreviations used)

Age considerationsPolicy includes pediatric (<18) specific prior‑trial requirements for some agents (see criteria per agent)

Documentation

Policy Revision History

Effective 2025-01-01annual_revisionLatest

Descriptor 'Choice/Alternate' added to the policy name; Humira (NDCs starting with 00074) and Hyrimoz (NDCs starting with 61314) were removed from Preferred Products throughout the policy (prior trials of those NDCs still count toward adalimumab trials); Tremfya subcutaneous and Omvoh subcutaneous were added as Preferred Products for Ulcerative Colitis; Omvoh moved from Step 2a to Preferred (Step 1); multiple agents and indication mappings were updated accordingly.

2024-10-30annual_review

Multiple preferred-product updates: Humira (NDCs starting with 00074) and Hyrimoz (NDCs starting with 61314) removed from Preferred Products for several indications; clarified Tremfya is the subcutaneous formulation and other product-level changes recorded (annual revision reviewed 10/30/2024).

OpenPayer

Inflammatory Conditions Preferred Specialty Management (Rheumatology)

Coverage Criteria and Indication-Specific Rules

Coding and Verification Parameters

Provider Requirements, Prior Authorization & Documentation

Background and Policy Context

Definitions and Abbreviations

Policy Revision History