CurrentMass General Brigham Health PlanPolicy N/A

Enbrel (etanercept) prior authorization and coverage criteria

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Defines prior authorization requirements, clinical criteria, limits, and reauthorization conditions for Enbrel (etanercept) under the Commercial/Exchange pharmacy benefit for Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyEnbrel (etanercept) prior authorization and coverage criteria

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateMay 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with medical records for members new to the plan (≤90 days) or meet diagnosis-specific trial criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial/ExchangePlan applicability

24 months

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CurrentMass General Brigham Health PlanPolicy N/A

Enbrel (etanercept) prior authorization and coverage criteria

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Sign up for all Mass General Brigham Health Plan policy alerts

Know when Mass General Brigham Health Plan releases new policies or updates existing guidance.

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Policy Summary

PayerMass General Brigham Health Plan

PolicyEnbrel (etanercept) prior authorization and coverage criteria

Policy CodePolicy N/A

Change TypeRoutine review — no material changes

Effective DateMay 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with medical records for members new to the plan (≤90 days) or meet diagnosis-specific trial criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial/ExchangePlan applicability

24 months

Coverage and Medical Necessity Criteria

Initial therapy criteria by indication

Authorization may be granted when ALL of the following are met (or for new-to-plan members, submission of records showing current treatment):

New-to-plan provision: If member is new to the plan (coverage effective date <= 90 days), submission of medical records documenting the member is currently receiving the requested drug qualifies

Excludes samples or manufacturer patient assistance program supplies

Rheumatoid arthritis: Diagnosis of moderately to severely active rheumatoid arthritis AND minimum 3-month trial and failure, contraindication, or intolerance to ONE of methotrexate, leflunomide, or sulfasalazine at maximally tolerated doses

Polyarticular JIA: Diagnosis of moderately to severely active polyarticular juvenile idiopathic arthritis AND minimum 6-week trial and failure, contraindication, or intolerance to ONE of leflunomide or methotrexate at maximally tolerated doses

Psoriatic arthritis: Diagnosis of active psoriatic arthritis AND member meets ONE of: actively inflamed joints, dactylitis, enthesitis, axial disease, OR active skin and/or nail involvement

Ankylosing spondylitis: Diagnosis of active ankylosing spondylitis AND minimum 1-month trial and failure, contraindication, or intolerance to TWO different NSAIDs at maximally tolerated doses

Plaque psoriasis: Diagnosis of moderate to severe chronic plaque psoriasis AND at least 3% body surface area affected OR crucial body areas involved AND ONE of: minimum 4-week trial and failure, contraindication, or intolerance to ONE topical therapy (corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar) OR severe psoriasis warranting biologic DMARD as first-line therapy>=3% BSA

Continuation Therapy

Continuation (reauthorization) criteria

Reauthorization: Submission of medical records (e.g., chart notes) demonstrating improvement in the member's condition as evidenced by low disease activity or improvement in signs and symptoms

This policy does not list any explicit off‑label uses or diagnoses that are excluded from coverage. The document’s overview and coverage guidance present the approved indications and the indication‑specific clinical requirements without naming additional off‑label or expressly excluded diagnoses.

The policy does not specify any additional not medically necessary conditions, numeric limits beyond those in the coverage criteria, or other unspecified denial criteria; no separate list of items described as “not specified” appears in the document.

Coding and Measurement Thresholds

Psoriasis body surface area threshold for moderate-severe disease

Psoriasis BSA threshold>= 3% body surface area (BSA)

Alternate qualifying criterionCrucial body areas involved (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

Context for thresholdApplies to diagnosis of moderate to severe chronic plaque psoriasis for biologic therapy eligibility

Provider Requirements, Documentation, and Denial Triggers

Prior Authorization

Prior authorization required; new-to-plan documentation (≤90 days)

Prior authorization is required for Enbrel (etanercept) under the pharmacy benefit. For members new to the plan (coverage effective date ≤90 days), submit medical records documenting the member is currently receiving the requested drug (excluding samples or manufacturer patient assistance program supplies).

Step Therapy

Indication-specific prior therapy requirements and durations

Required therapy trials vary by indication — confirm the specific prior therapies and minimum trial durations per diagnosis before requesting authorization.

Rheumatoid arthritis (RA): ≥3-month trial and failure, contraindication, or intolerance to ONE of methotrexate, leflunomide, or sulfasalazine (maximally tolerated doses).
Polyarticular juvenile idiopathic arthritis (pJIA): ≥6-week trial and failure, contraindication, or intolerance to ONE of leflunomide or methotrexate (maximally tolerated doses).
Ankylosing spondylitis (AS): ≥1-month trial and failure, contraindication, or intolerance to TWO different NSAIDs (maximally tolerated doses).

Indications and Age/Population Definitions

Approved indications — Enbrel (etanercept)

Adult approved indicationsRheumatoid arthritis; Psoriatic arthritis; Ankylosing spondylitis; Plaque psoriasis

Pediatric approved indications (age ≥2)Polyarticular juvenile idiopathic arthritis (pJIA) and Juvenile psoriatic arthritis

Pediatric approved indication (age ≥4)Plaque psoriasis

Drug classTumor necrosis factor (TNF) blocker (etanercept)

Clinical Background

Enbrel (etanercept) is a tumor necrosis factor (TNF) blocker used to treat multiple inflammatory conditions in adults and children. Approved adult indications include rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis; pediatric approvals include polyarticular juvenile idiopathic arthritis (≥2 years), juvenile psoriatic arthritis (≥2 years), and plaque psoriasis (≥4 years). Under this plan, Enbrel is covered through the pharmacy benefit and is designated as a specialty medication that must be dispensed at a contracted specialty pharmacy.