Criteria for Prior Authorization — Adult Rheumatoid Arthritis Agents
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Defines prior authorization requirements for adult rheumatoid arthritis (RA) biologic and JAK inhibitor agents for Kansas Medicaid, including initial and renewal criteria, dosing/age limits, and length of approval.
No material clinical or coverage changes in this revision.
Coverage Criteria for Adult Rheumatoid Arthritis Agents
Initial Therapy — Covered when ALL of the following are met for initial authorization:
Covered when ALL of the following are met for initial authorization:
Must also meet agent-specific age and dosing limits in Table 1.
Continuation/Renewal Therapy — Renewal authorization must meet ALL of the following:
Renewal authorization — must meet ALL of the following:
Length of renewal approval is 12 months.
Medications used for cosmetic purposes or for other FDA-approved indications that are not covered under state policy are excluded from coverage unless the state policy explicitly specifies otherwise. This exclusion follows federal statute, 42 USC § 1396R-8(D)(2), and applies to PA requests unless an exception is noted in state policy.
Use is not supported when required prerequisites are not documented. Prior authorization for initial therapy requires documentation that the agent is FDA-approved for the indicated use, meets age and dosing limits, was prescribed by or in consultation with a rheumatologist, and that the patient had an adequate trial (at least 90 consecutive days) of methotrexate or, if methotrexate is contraindicated, an adequate trial of another conventional therapy from Table 2 or contraindications to all conventional therapies. For baricitinib, tofacitinib, and upadacitinib, documentation must also show an adequate trial (at least 6–8 weeks) of at least one TNF blocker or contraindications to all TNF blockers. Baseline disease activity must be provided using one accepted measure (PAS/PAS-II, RAPID3, CDAI, DAS28, or SDAI), and the patient must not be concurrently receiving another listed immunomodulating biologic or JAK inhibitor. Failure to meet these prerequisites may result in denial of prior authorization.
Covered Agents, Codes and Disease Activity Thresholds
| Abatacept | Orencia® |
| Adalimumab | Humira®, Abrilada™, Amjevita™, Cyltezo®, Hadlima™, Hulio®, Hyrimoz®, Idacio®, Simlandi®, Yuflyma®, Yusimry™ |
| Anakinra | Kineret® |
| Baricitinib | Olumiant® |
| Certolizumab | Cimzia® |
| Etanercept | Enbrel® |
| Golimumab | Simponi®, Simponi Aria® |
| Infliximab | Remicade®, Avsola®, Inflectra®, Renflexis® |
| Rituximab | Rituxan®, Riabni™, Ruxience®, Truxima® |
| Sarilumab | Kevzara® |
Actions Required by Prescribers and Denial Triggers
Prior authorization required for all listed RA biologic and JAK agents
Prior authorization is required for all listed adult rheumatoid arthritis biologic agents and JAK inhibitors and for all current and future dose forms; approval requires that the agent meet the FDA‑approved indication, age, and dosing limits in Table 1 and be prescribed by or in consultation with a rheumatologist.
- Applies to all agents listed in Table 1 (e.g., abatacept, adalimumab, anakinra, baricitinib, certolizumab, etanercept, golimumab, infliximab, rituximab, sarilumab, tocilizumab, tofacitinib, upadacitinib).
- PA will be reviewed against indication, age, dose, and prerequisite treatment requirements.
Required step therapy trials before authorization
Before initiating a biologic or JAK inhibitor, document an adequate trial of methotrexate for at least 90 consecutive days or a contraindication to methotrexate plus an adequate trial of at least one other conventional therapy from Table 2. For baricitinib, tofacitinib, and upadacitinib, the patient must also have had an adequate trial (6–8 weeks) of at least one TNF blocker or have contraindications to all TNF blockers.
- Adequate methotrexate trial = ≥ 90 consecutive days, unless contraindicated.
- TNF‑blocker trial for baricitinib/tofacitinib/upadacitinib = ≥ 6–8 weeks (unless contraindicated).
Document baseline disease activity and prior therapy trials
Prescriber must provide a baseline disease activity score using one accepted instrument and evidence of required prior therapy trials when requesting PA.
- Acceptable baseline scores: PAS or PAS‑II > 3.7; RAPID3 > 2.0; CDAI > 10; DAS28 ≥ 3.2; or SDAI > 11.0.
- Document prior therapy trials (e.g., ≥90 days methotrexate or alternative conventional therapy) and prescriber specialty (rheumatologist or consultation).
Denial triggers for initial and renewal requests
Requests may be denied if initial or renewal criteria are not fully met.
- Common denial triggers: inadequate documented trials of required conventional therapies (including methotrexate requirement), missing baseline or response disease activity scores, or concurrent use of another immunomodulating biologic or JAK inhibitor.
- Renewal denials can occur if response measures (e.g., PAS/PAS‑II ≤3.7, RAPID3 ≤2.0, CDAI ≤10, DAS28 <3.2, SDAI ≤11) are not documented or dosing limits are exceeded.
Policy Background and Definitions
This policy governs prior authorization for the use of immunomodulating biologic agents and janus kinase (JAK) inhibitors in adults with moderate to severe active rheumatoid arthritis. Authorization is aligned with FDA-approved indications, age and dosing limits, and requires guideline-consistent prior conventional therapy trials, prescriber qualifications, and documentation of baseline disease activity using one of the accepted scoring instruments.
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