CurrentCignaPolicy PSM017

Inflammatory Conditions Preferred Specialty Management Policy for Employer Plans: Legacy Prescription Drug Lists

Defines preferred and non-preferred specialty drug products for inflammatory conditions (rheumatology, dermatology, gastroenterology) and the exception/prior authorization criteria required to approve non-preferred products for Cigna employer legacy prescription drug lists.

Policy Summary

PayerCigna

PolicyInflammatory Conditions Preferred Specialty Management Policy for Employer Plans: Legacy Prescription Drug Lists

Policy CodePolicy PSM017

Change TypeMultiple revisions and additions across preferred/non-preferred lists (see changes)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionProviders must submit and satisfy the respective standard Inflammatory Conditions Prior Authorization Policy criteria for the requested product (product-specific PA required).

POLICY UPDATE CHANGES

New policy created relocating legacy Drug List Plans criteria to PSM017 from PSM001.

Throughout the policy, NDCs starting with 61314 (Hyrimoz) were removed from Preferred Products and a previous trial of these NDCs counts towards an adalimumab trial.

Tremfya subcutaneous was added as a Preferred Product for Ulcerative Colitis and Crohn's Disease (where noted).

Cimzia was added to Step 3a for Juvenile Idiopathic Arthritis and as an agent that counts toward a trial of a Preferred Product in several JIA-related updates.

Bimzelx added to Step 2a for certain indications and to Step 2b for Hidradenitis Suppurativa with direction to trial one Preferred Product.

Velsipity added as a Preferred Product for Ulcerative Colitis (and added to multiple agents' Preferred lists for UC).

Omvoh subcutaneous moved from Step 2a to Preferred (Step 1) for Crohn's Disease and Ulcerative Colitis; Omvoh SC added as Preferred product in several places.

Multiple ustekinumab subcutaneous products (Selarsdi, ustekinumab-ttwe, Yesintek, etc.) were added as Preferred products and the note clarified that trials of multiple ustekinumab products count as one product.

Tremfya SC added as a Preferred Product for Crohn's Disease in some revisions; criteria updated to include Tremfya SC and Tremfya IV counting where specified.

Adalimumab-adaz was removed as a Preferred Product throughout the policy.

Many entries clarified that Tremfya refers to the subcutaneous formulation.

Policy note updated listing examples of ustekinumab products and included additional brand/generic names.

PSM017Policy identifier

2025-01-01Policy effective date

3-6 mo / 1 yrApproval durations

130-day look-backContinuation verification window

90-day / 130-dayEstablished therapy verification

MultipleConditions covered

Coverage Summary

This policy implements Cigna's Preferred vs Non-Preferred step-therapy framework for multiple biologic and oral therapies used in inflammatory conditions across rheumatology, dermatology, and gastroenterology. FDA-approved indications for products referenced in the policy are listed in Appendix A (not included here). The policy is identified as PSM017 with an effective date noted in the policy header. Non-preferred products are covered only when the specified product- and indication-specific exception/prior authorization criteria are met (covered_with_criteria).

Key thresholds & operational highlights

Continuation verification look-back>= 90 days therapy dispensed within past 130 days (verification in prescription claims) OR prescriber verification when claims unavailable

Typical approval durationsInitial: often 3–6 months (example initial approvals 3 or 6 months); Continuation: generally 1 year

Established therapy verificationEstablished on therapy defined as at least a 90-day supply dispensed within the past 130 days (claims verification) or prescriber attestation if claims unavailable

Established therapy verification (continuation rule)For continuation approvals, must show >=90 days on therapy and claims indicate >=90-day supply dispensed within past 130 days OR prescriber verification that paid claims support prior use (no samples/coupons)

Continuation verification look-back (specific wording)>= 90 days within past 130 days OR prescriber verification when claims history unavailable

Policy identifierPSM017

Policy effective date2025-01-01

Preferred / Non-Preferred Step Therapy Framework

Preferred / Non-Preferred Step Therapy Framework (by indication groups)

ALL of the following

Step 1 Preferred - Rheumatology
- Enbrel (etanercept)
- Adalimumab Products (including Cyltezo, adalimumab-adbm, Simlandi, adalimumab-ryvk, Humira)
Step 1 Preferred - Dermatology
- Otezla (apremilast)
- Skyrizi (risankizumab) SC

General Program Requirements

For all medications, this program requires the patient to meet the respective standard Prior Authorization Policy criteria and trials of Preferred Product(s) when clinically appropriate:

Meet standard product-specific PA criteria: Patient meets the respective standard Inflammatory Conditions Prior Authorization Policy criteria (by product).
Refer to respective standard Prior Authorization Policy for product-specific baseline criteria.
Trials of Preferred Products: Trials of Preferred Product(s) are required prior to approval of Non-Preferred Products when clinically appropriate.
Documentation of trials may be required; see product-specific sections.
Continuation verification: Continuation of therapy: verification by prescription claims history (130-day look-back) OR verification by prescriber when claims history unavailable.

Product-specific Initial and Continuation Criteria (selected agents)

Cimzia (certolizumab) Exception Criteria (selected indications present in this part)

Non-preferred Cimzia may be approved per indication when BOTH the standard Cimzia PA criteria are met AND directed prior trials/documentation are satisfied.

Rheumatoid Arthritis - Initial Therapy

Standard PA: Patient meets the standard Inflammatory Conditions - Cimzia Prior Authorization Policy criteria.
Refer to standard Cimzia PA.
Prior trials: Patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR.documentation required
Examples and product-counting rules noted in policy; multiple products of same molecule count as one.

Ankylosing Spondylitis - Initial Therapy

Unproven / Exclusions

Any non-preferred product that does not meet the applicable product-specific exception criteria is considered not medically necessary. Receipt of sample product does not satisfy criteria for coverage. Documentation required for prior trials includes chart notes, prescription claims records, and/or prescription receipts. When counting prior trials, multiple products of the same molecule (for example, multiple adalimumab products or multiple ustekinumab products) count as ONE product trial; likewise different formulations of the same product (e.g., Xeljanz and Xeljanz XR) count collectively as ONE trial.

Provider Actions & Documentation Requirements

Prior authorization and documentation callouts

Note

Applicable Codes & Referenced Policy Identifiers

Background & Definitions

The policy notes that the FDA-approved indications for each product are documented in Appendix A (not included in this excerpt). This document relocates legacy Drug List Plans criteria into the new policy structure (PSM017) and implements the preferred-product step-therapy approach across numerous biologic and oral agents, moving prior criteria from prior policy versions into this consolidated preferred vs non-preferred framework.

Term	Definition
Step 1/Step 2/Step 3
Internal formulary/step categories where Step 1 = Preferred products and Step 2/3 = Non-preferred products that may require directed trials of Step 1 (or Step 2) products.
Documentation required
Prescriber must provide chart notes, prescription claims records, or receipts verifying trials of required products (documentation may include chart notes, claims records, prescription receipts).
Trial counts
A trial of multiple products from the same molecule/class (e.g., multiple adalimumab products or multiple ustekinumab products) counts as ONE product trial; both formulations of a product (e.g., Xeljanz and Xeljanz XR) count collectively as ONE trial.
Established on therapy
Prescriber report or prescription claims history indicating patient has been receiving the drug for at least 90 days; claims verification requires ≥90-day supply dispensed within past 130 days (or prescriber verification if claims unavailable).
TNFis
Tumor necrosis factor inhibitors (examples: adalimumab products, Enbrel [etanercept], Cimzia [certolizumab], Simponi [golimumab], infliximab products including Zymfentra).
tsDMARDs
Targeted synthetic disease‑modifying antirheumatic drugs (examples: Olumiant [baricitinib], Rinvoq [upadacitinib], Xeljanz/XR [tofacitinib]).
JIA
Juvenile idiopathic arthritis.
RA
Rheumatoid arthritis.
CD
Crohn's disease.
UC
Ulcerative colitis.

Clinical Evidence & Rationale

No discrete trial-level clinical evidence is provided in this policy text. Approvals and denials follow the referenced standard product-specific prior authorization (PA) policies; where evidence bases are needed, reviewers should consult the respective standard PA policy documents for each product for the clinical evidence and rationale that support product-specific criteria.

Revision History

01/01/2025revised

New policy created relocating legacy Drug List Plans criteria to PSM017 from PSM001.

01/01/2025revised

Throughout the policy, NDCs starting with 61314 (Hyrimoz) were removed from Preferred Products and a previous trial of these NDCs counts towards a trial of an adalimumab product.

01/01/2025added

Tremfya subcutaneous was added as a Preferred Product for Ulcerative Colitis (clarified Tremfya SC where referenced).

Policy Summary

PayerCigna

PolicyInflammatory Conditions Preferred Specialty Management Policy for Employer Plans: Legacy Prescription Drug Lists

Policy CodePolicy PSM017

Change TypeMultiple revisions and additions across preferred/non-preferred lists (see changes)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionProviders must submit and satisfy the respective standard Inflammatory Conditions Prior Authorization Policy criteria for the requested product (product-specific PA required).

On This Page

Ustekinumab SC products (Stelara, Selarsdi, ustekinumab-ttwe, Yesintek)

Step 1 Preferred - Gastroenterology

Skyrizi (risankizumab) SC
Entyvio (vedolizumab)

Claims must show specified supply (90 or 120 days) within 130 days; if not available prescriber must verify duration and that therapy was via paid claims (no samples/coupons).

Approval duration guidance: Approval duration: continuation approvals generally provided for 1 year unless otherwise noted.

When initial approval authorized in months, 1 month = 30 days.

Standard PA: Patient meets standard Cimzia PA criteria.
Prior trials: Patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR.documentation required

Juvenile Idiopathic Arthritis - Initial Therapy

Standard PA: Patient meets standard Cimzia PA criteria.
Acceptable trial sets
- Set A: Patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, and Xeljanz.documentation required
  Trials count rules apply.
- Alternate counted agents: A trial of tocilizumab IV (Actemra IV biosimilar), Kevzara, Orencia IV/SC, an infliximab product (e.g., Remicade, biosimilars), or Simponi Aria also counts.documentation required

Psoriatic Arthritis - Initial Therapy

Standard PA: Patient meets standard Cimzia PA criteria.
Prior trials: Patient 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

Plaque Psoriasis - Initial Therapy

Standard PA: Patient meets standard Cimzia PA criteria.
Prior trials: Patient has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi SC, Sotyktu, an ustekinumab SC product, Taltz, or Tremfya SC.documentation required

Crohn's Disease - Initial Therapy

Standard PA: Patient meets standard Cimzia PA criteria.
Prior trials: Patient has tried ONE adalimumab product.documentation required
Examples provided; counts toward trial per policy.

Patient currently receiving Cimzia (continuation)

Must meet ONE of
- Indication-specific prior trials met: Indication-specific prior trials as detailed (e.g., RA: tried TWO of specified agents; AS: tried TWO; JIA: tried TWO or acceptable alternatives; PsA: tried TWO; Plaque Psoriasis: tried TWO; Crohn's: tried one adalimumab).documentation required
- Established use verification: Patient has been established on Cimzia ≥90 days and prescription claims history indicates ≥90-day supply dispensed within past 130 days OR verification by prescriber if claims unavailable.claims verification required
  No samples/coupons; prescriber attestation allowed when claims unavailable.

Simponi (golimumab) Subcutaneous Exception Criteria (selected indications)

Non-preferred Simponi SC may be approved when standard Simponi PA criteria are met and required prior trials are documented.

Rheumatoid Arthritis - Initial Therapy

Standard PA: Patient meets the standard Inflammatory Conditions - Simponi Subcutaneous Prior Authorization Policy criteria.
Prior trials: Patient has tried TWO of a tocilizumab subcutaneous product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR.documentation required

Ankylosing Spondylitis - Initial Therapy

Standard PA: Patient meets standard Simponi SC PA criteria.
Prior trials: Patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, or Xeljanz/XR.documentation required

Psoriatic Arthritis - Initial Therapy

Standard PA: Patient meets standard Simponi SC PA criteria.
Prior trials: Patient 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

Ulcerative Colitis - Initial Therapy

Standard PA: Patient meets standard Simponi SC PA criteria.
Prior trials: Patient has tried ONE adalimumab product.documentation required
Approve for 6 months if criteria met.

Patient currently receiving Simponi SC or Aria (continuation)

ONE of
- Indication-specific prior trials met: Patient meets ONE of the indication-specific prior trial options (e.g., RA tried two of specified agents; AS tried two; etc.).documentation required
- Established use Simponi Aria: Patient has been established on Simponi Aria for at least 90 days.
- Established use Simponi SC: Patient has been established on Simponi subcutaneous ≥90 days and claims indicate ≥90-day supply dispensed within past 130 days OR prescriber verification if claims unavailable.claims verification required
  No samples/coupons; prescriber attestation allowed when claims unavailable.

Simponi SC/Aria - Ulcerative Colitis - Alternative review: If standard criteria met but the product-specific trial criterion is not met, requests for Preferred Products may be reviewed under respective PA criteria.

Alternatives listed by indication in document.

Zymfentra - All Conditions

Approve when patient meets standard Zymfentra PA criteria

Zymfentra - All Conditions: Patient meets the standard Inflammatory Conditions - Zymfentra Prior Authorization Policy criteria.

Actemra (Tocilizumab) Subcutaneous/IV and Kevzara (sarilumab) - Initial and Currently Receiving

Actemra (tocilizumab) subcutaneous/Tyenne subcutaneous initial therapy and continuation rules and Kevzara initial and continuation rules described below; preserve ONE-of branches and establishment verification.

Actemra/Tyenne - Polyarticular JIA and RA - Initial Therapy: Patient meets the standard Inflammatory Conditions - Tocilizumab Subcutaneous Prior Authorization Policy criteria and meets ONE of: tried one adalimumab product OR prescriber reports heart failure or previously treated lymphoproliferative disorder.6 months

If criterion not met, request may be reviewed for preferred products.

Actemra/Tyenne - Currently Receiving (SC/IV): Patient meets the standard Tocilizumab PA criteria and meets ONE of listed conditions (e.g., PJIA or RA tried one adalimumab product; prescriber reports heart failure/lymphoproliferative disorder; established on IV ≥90 days; established on SC ≥90 days with claims verification or prescriber attestation).1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Kevzara - Rheumatoid Arthritis & JIA - Initial Therapy: Patient meets the standard Kevzara PA criteria and meets ONE of: has tried TWO of a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR OR prescriber reports heart failure or previously treated lymphoproliferative disorder.6 months

Documentation required for trials; alternative review allowed if criterion not met.

Kevzara - Currently Receiving: Patient meets the standard Kevzara PA criteria and meets ONE of disease-specific trial options OR prescriber clinical exclusion OR established on Kevzara ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Kevzara - Initial and Currently Receiving

Kevzara initial and continuation rules (see Actemra section above for related cross-counting).

Kevzara - Initial Therapy (RA/JIA): Patient meets standard Kevzara PA criteria and meets ONE of the listed trial options (e.g., tried TWO of tocilizumab SC, Enbrel, adalimumab, Rinvoq, Xeljanz/XR) or prescriber documents heart failure/lymphoproliferative disorder.6 months

Documentation required; alternative review allowed if criterion not met.

Kevzara - Currently Receiving: Patient meets standard Kevzara PA criteria and meets ONE of the disease-specific prior trials OR clinical exclusion OR has been established on Kevzara ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Bimzelx (IL-17 blocker) - Multiple Indications - Initial & Currently Receiving

Bimzelx initial and continuation criteria vary by indication with 90-day establishment verification for continuation.

Bimzelx - Multiple Indications - Initial Therapy: Patient meets the standard Inflammatory Conditions - Bimzelx Prior Authorization Policy criteria and has tried indication-specific prior therapies (varies by indication: AS, HS, nr-axSpA, Plaque Psoriasis, PsA).varies by indication

Documentation required; directed to one or more Step 1 products as specified.

Bimzelx - Currently Receiving: Patient meets standard Bimzelx PA criteria and meets indication-specific prior trials OR has been established on Bimzelx ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Cosentyx (Subcutaneous/IV) - Multiple Indications - Initial & Currently Receiving

Cosentyx (subcutaneous/IV) initial and continuation across multiple indications; pediatric vs adult PsA differences preserved.

Cosentyx - Initial Therapy (Multiple Indications): Patient meets the standard Inflammatory Conditions - Cosentyx Subcutaneous Prior Authorization Policy criteria and has tried indication-specific prior therapies (e.g., AS: TWO of Enbrel, adalimumab, Rinvoq, Taltz, Xeljanz/XR; nr-axSpA: TWO of Cimzia, Taltz, Rinvoq; Plaque Psoriasis: TWO of Enbrel, adalimumab, Otezla, Skyrizi SC, Sotyktu, ustekinumab SC, Taltz, Tremfya SC).3 or 6 months per indication

Documentation required; trials of multiple products of same molecule count as one.

Cosentyx - Psoriatic Arthritis Initial (age-specific): Adult (≥18): tried TWO of specified agents; Pediatric (<18): tried ONE of Enbrel, Rinvoq/Rinvoq LQ, or an ustekinumab SC product.6 months

Documentation required.

Cosentyx - Currently Receiving: Patient meets standard Cosentyx PA criteria and meets ONE of indication-specific prior trials OR has been established on Cosentyx IV ≥90 days OR established on Cosentyx SC ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Cosentyx - Alternate review when criterion 5Aii not met: If standard Cosentyx SC criteria met but product-specific trial not met, requests for listed alternative products may be reviewed under respective standard PA policies.

Alternative product lists provided by indication.

Siliq, Ilumya, Skyrizi/Tremfya/Stelara/Ustekinumab-class continuation

Siliq and Ilumya initial 3-month approvals and 1-year continuation rules; class continuation note for Skyrizi/Tremfya/Stelara/Ustekinumab products referencing respective PA policies.

Siliq - Plaque Psoriasis Initial Therapy: Patient meets the standard Inflammatory Conditions - Siliq PA criteria and has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi SC, Sotyktu, an ustekinumab SC product, Taltz, or Tremfya SC.3 months

Documentation required.

Siliq - Currently Receiving: Patient meets standard Siliq PA criteria and meets TWO-trial requirement OR has been established on Siliq ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Ilumya - Plaque Psoriasis Initial Therapy: Patient meets the standard Inflammatory Conditions - Ilumya PA criteria and has tried TWO of Enbrel, an adalimumab product, Otezla, Skyrizi SC, Sotyktu, an ustekinumab SC product, Taltz, or Tremfya SC.3 months

Documentation required.

Ilumya - Currently Receiving: Patient meets standard Ilumya PA criteria and meets TWO-trial requirement OR has been established on Ilumya ≥90 days with claims verification or prescriber attestation.1 year

Claims verification required as noted.

Skyrizi/Tremfya/Stelara/Ustekinumab-class - continuation: Approve these products when patient meets respective standard PA criteria (initial as directed or 1 year continuation).

Refer to respective standard Inflammatory Conditions PA policies.

Entyvio - Plaque Psoriasis, Ulcerative Colitis, Crohn's continuation and alternate review

Entyvio SC initial and continuation criteria across Plaque Psoriasis, Ulcerative Colitis, Crohn's with induction therapy note and alternate review when trial criteria not met.

Entyvio - Plaque Psoriasis Initial Therapy: Patient meets standard Entyvio SC PA criteria and has tried TWO of an adalimumab product, Skyrizi SC, Tremfya SC, an ustekinumab SC product, Zymfentra, Omvoh SC, Cimzia, or Rinvoq OR per prescriber has started/undergoing Entyvio IV induction.6 months

Documentation required; induction therapy note applies.

Entyvio - Ulcerative Colitis Initial Therapy: Patient meets standard Entyvio SC PA criteria and has tried TWO of an adalimumab product, Skyrizi SC, an ustekinumab SC product, Zymfentra, Omvoh SC, Rinvoq, Simponi SC, Tremfya SC, Velsipity, or Xeljanz/XR OR per prescriber has started/undergoing Entyvio IV induction.6 months

Documentation required; prescriber induction verification acceptable.

Entyvio - Crohn's & Ulcerative Colitis continuation: Patient meets standard Entyvio SC PA criteria and meets disease-specific two-trial requirements OR has been established on Entyvio IV ≥90 days OR Entyvio SC ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Entyvio - Alternate product review when criterion not met: If Entyvio criteria partially not met, Step 1/2 products may be reviewed under standard policies; alternative product lists by indication provided in policy.

Kineret - Rheumatoid Arthritis Initial & Currently Receiving

Kineret RA initial and continuation criteria with 90-day establishment verification and alternate review path when trial criteria not met.

Kineret - RA Initial Therapy: Patient meets standard Kineret PA criteria and has tried TWO of a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR.6 months

Documentation required; alternate agents may count per policy.

Kineret - Currently Receiving: Patient meets standard Kineret PA criteria and has tried TWO of listed agents OR has been established on Kineret ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Kineret - Alternate review if criterion 1Aii not met: If standard Kineret criteria met but product-specific trial not met, Step 1/2 product requests may be reviewed under respective policies (list provided).

Orencia - Subcutaneous (Inflammatory Conditions) - Initial, Currently Receiving, and Alternate exceptions

Orencia initial/continuation, alternate review, and subcutaneous exceptions including lists of alternative products and clinical exclusions preserved.

Orencia SC - RA Initial Therapy: Patient meets standard Orencia SC PA criteria and meets ONE of: tried TWO of tocilizumab SC, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR OR prescriber documents heart failure/lymphoproliferative disorder/previous serious infection/demyelinating disorder.6 months

Documentation required; alternate review allowed if criterion not met.

Orencia SC - JIA Initial Therapy: Patient meets standard Orencia SC PA criteria and meets ONE of: tried TWO of tocilizumab SC, Enbrel, an adalimumab product, Rinvoq/Rinvoq LQ, or Xeljanz OR prescriber documents clinical exclusions.6 months

Documentation required.

Orencia SC - Psoriatic Arthritis Initial Therapy: Patient meets standard Orencia SC PA criteria and meets ONE of: adult ≥18 tried TWO of listed agents; pediatric <18 tried ONE of listed agents; OR prescriber documents specified clinical exclusions.6 months

Documentation required; lists preserved.

Orencia - Currently Receiving (SC or IV): Patient meets standard Orencia PA criteria and meets one of disease-specific prior therapy trials OR has been established on Orencia IV ≥90 days OR Orencia SC ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Orencia - Alternate review when 4Ai met but 4Aii not met: If Orencia initial criteria partially met but product-specific prior therapy criterion not met, requests for listed alternative products may be reviewed under respective standard PA policies (alternative lists by indication included).

Lists include Actemra SC, Tyenne SC, Enbrel, Humira NDCs, adalimumab biosimilars, Rinvoq, Xeljanz, etc.

Orencia - Subcutaneous exceptions: Orencia SC may be approved when standard Orencia SC PA criteria met OR when defined exceptions apply: established on Orencia IV ≥90 days and/or prescriber clinical exclusions OR established on Orencia SC ≥90 days with claims verification.

Claims verification: ≥90-day supply within past 130 days or prescriber attestation when unavailable; samples not acceptable.

Olumiant (baricitinib) - Rheumatoid Arthritis

Olumiant initial and continuation per standard Olumiant PA policy with additional required trial history of two agents and continuation establishment verification.

Olumiant - Initial Therapy: Patient meets the standard Inflammatory Conditions - Olumiant PA criteria and has tried TWO of a tocilizumab SC product, Enbrel, an adalimumab product, Rinvoq, or Xeljanz/XR.6 months

Documentation required; multiple product-counting rules apply.

Olumiant - Patient currently receiving: Patient meets the standard Olumiant PA criteria and either has tried TWO of listed agents OR has been established on Olumiant ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Olumiant - Alternative review: If initial trial criterion not met, requests for Step 1/2 products may be reviewed under their respective PA criteria.

Rinvoq / Rinvoq LQ (upadacitinib) - Multiple Indications

Rinvoq / Rinvoq LQ mapping of initial trials per indication and continuation node with 90-day establishment verification preserved.

Rinvoq - Ankylosing Spondylitis Initial: Patient meets standard Rinvoq/LQ PA criteria and has tried one of Enbrel or an adalimumab product (Cimzia/infliximab/Simponi may count).6 months

Rinvoq - Crohn's Disease Initial: Patient meets standard Rinvoq/LQ PA criteria and has tried one adalimumab product (infliximab products or Cimzia may count).6 months

Rinvoq - Juvenile Idiopathic Arthritis Initial: Patient meets standard Rinvoq/LQ PA criteria and has tried one of Enbrel or an adalimumab product (Cimzia/infliximab/Simponi Aria may count).6 months

Rinvoq - nr-axSpA Initial: Patient meets standard Rinvoq/LQ PA criteria and has tried Cimzia.6 months

Rinvoq - Rheumatoid Arthritis Initial: Patient meets standard Rinvoq/LQ PA criteria and has tried one of Enbrel or an adalimumab product.6 months

Rinvoq - Psoriatic Arthritis Initial: Patient meets standard Rinvoq/LQ PA criteria and has tried one of Enbrel or an adalimumab product.6 months

Rinvoq - Ulcerative Colitis Initial: Patient meets standard Rinvoq/LQ PA criteria and has tried one adalimumab product.6 months

Currently Receiving Rinvoq (continuation): Patient meets standard Rinvoq/LQ PA criteria and meets specified disease-specific prior biologic/therapy trial requirements OR has been established on Rinvoq ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Rinvoq - Alternative review: If criteria not met, requests may be reviewed under standard PA criteria for listed preferred products by indication.

Xeljanz / Xeljanz XR / Xeljanz oral solution - Multiple Indications

Xeljanz/XR/oral solution initial and continuation criteria by indication and currently receiving verification rules; alternative review note when criteria not met.

Xeljanz/XR - Ankylosing Spondylitis Initial: Patient meets standard Xeljanz/XR PA criteria and has tried one of Enbrel or an adalimumab product.6 months

Xeljanz/XR - Rheumatoid Arthritis Initial: Patient meets standard Xeljanz/XR PA criteria and has tried one of Enbrel or an adalimumab product.6 months

Xeljanz/XR - Juvenile Idiopathic Arthritis Initial: Patient meets standard Xeljanz/XR PA criteria and has tried one of Enbrel or an adalimumab product.6 months

Xeljanz/XR - Psoriatic Arthritis Initial: Patient meets standard Xeljanz/XR PA criteria and has tried one of Enbrel or an adalimumab product.6 months

Xeljanz/XR - Ulcerative Colitis Initial: Patient meets standard Xeljanz/XR PA criteria and has tried one adalimumab product (infliximab or Simponi SC may count).6 months

Currently Receiving Xeljanz/XR (continuation): Patient meets standard Xeljanz/XR PA criteria and meets disease-specific prior biologic/therapy trial requirements OR has been established on Xeljanz/XR ≥90 days with claims verification or prescriber attestation.1 year

Claims verification: ≥90-day supply dispensed within past 130 days or prescriber verification if claims unavailable.

Xeljanz oral solution - Other Conditions: Approve Xeljanz oral solution (initial therapy for duration as directed or 1 year for continuing therapy) if patient meets standard Xeljanz/XR PA criteria.

Other specialty drugs referenced (Otezla, Velsipity, Zeposia, Sotyktu)

Other specialty oral/ injectable agents approved when standard PA criteria are met.

Other specialty drugs referenced (Otezla, Velsipity, Zeposia, Sotyktu): Approve listed products if patient meets respective standard Inflammatory Conditions (or MS/UC for Zeposia) Prior Authorization Policy criteria.

Includes Otezla, Velsipity, Zeposia, Sotyktu per referenced PA policies.

Other Conditions / Approvals referencing standard PA policies

Generic approvals referencing standard PA policies and operational rules (dosage, site of care, samples).

Other Conditions / Approvals referencing standard PA policies: Approve listed oral or injectable agents if patient meets referenced standard Prior Authorization Policy criteria (e.g., Xeljanz oral solution, Otezla, Velsipity, Zeposia, Sotyktu).

Continuation/initial approval when meeting referenced criteria: Approve when patient meets referenced standard PA criteria; dosage/frequency/duration/site of care must be clinically appropriate; receipt of sample product does not satisfy criteria.

Receipt of sample product does not satisfy any criteria requirements for coverage.

Continuation verification and step-therapy alternatives

Note

01/01/2025added

Cimzia was added to Step 3a for Juvenile Idiopathic Arthritis and as an agent that counts toward a trial of a Preferred Product in JIA-related updates; documentation of a trial of two Step 1 or 2a Products is required.

01/01/2025added

Bimzelx added to Step 2a for certain indications and to Step 2b for Hidradenitis Suppurativa with direction to trial one Preferred Product.

03/15/2025added

Velsipity added as a Preferred Product for Ulcerative Colitis and added to multiple agents' Preferred lists for UC.

04/01/2025revised

Omvoh subcutaneous moved from Step 2a to Preferred (Step 1) for Crohn's Disease and Ulcerative Colitis; Omvoh SC added as Preferred product in several places.

04/15/2025added

05/15/2025revised

Tremfya SC added as a Preferred Product for Crohn's Disease in some revisions; criteria updated to include Tremfya SC and Tremfya IV counting where specified.

05/15/2025removed

Adalimumab-adaz was removed as a Preferred Product throughout the policy.

09/01/2025revisedLatest

Policy note updated listing examples of ustekinumab products and included additional brand/generic names (Stelara, Wezlana, Otufli, Pyzchiva, ustekinumab-ttwe, Selarsdi, Steqeyma, Yesintek).