Currentmedical mutual - ohioPolicy N/A

Non-Preferred vs Preferred biologic and targeted therapies for inflammatory conditions (rheumatology, dermatology, gastroenterology)

Defines a multi-step preferred/non-preferred formulary and prior authorization requirements for multiple biologic and targeted oral therapies used in inflammatory conditions (RA, AS, nr-axSpA, JIA, PsA, plaque psoriasis, HS, Crohn's disease, ulcerative colitis). Specifies required trials of preferred products (Step 1) and directed trials of Step 2/3 products, continuation criteria, documentation and approval durations.

Policy Summary

Payermedical mutual - ohio

PolicyNon-Preferred vs Preferred biologic and targeted therapies for inflammatory conditions (rheumatology, dermatology, gastroenterology)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization and document required trials of Preferred/Step 1 products per the respective standard Inflammatory Conditions PA policies.

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported in this brief.

9Indications covered with criteria

Step-basedFormulary step structure

≥90dEstablished therapy requirement

130dClaims lookback window

Multiple

Therapies referenced

Coverage Summary

Defines a multi-step preferred/non-preferred formulary and prior authorization program for multiple biologic and targeted oral therapies used across inflammatory conditions (RA, AS, nr-axSpA, JIA, PsA, plaque psoriasis, hidradenitis suppurativa, Crohn's disease, and ulcerative colitis). For medications in scope, standard product-specific Prior Authorization (PA) policies apply and the program requires trials of Preferred (Step 1) products per the step table before approval of many Non-Preferred agents. Continuation of therapy approvals and documentation rules are specified (continuation verifications rely on prescription claims history lookback or prescriber verification) and most continuation approvals are provided for 1 year unless noted otherwise.

Prior Authorization & Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required per standard Inflammatory Conditions prior authorization policies. All Non-Preferred products in this program require prior authorization consistent with the Medical Mutual of Ohio standard Prior Authorization Policies for inflammatory conditions. Refer to the selected standard Prior Authorization Policies for condition-specific clinical criteria.

Prior Authorization required per standard Inflammatory Conditions prior authorization policies
Refer to selected standard Prior Authorization Policies for condition-specific criteria
Continuation verification for Non-Preferred products is required

Prior Authorization

Approval Duration & Continuation Verification

Approval durations and continuation verification. Approvals for continuation of therapy for Preferred and Non-Preferred products are provided for 1 year unless noted otherwise. Continuation of therapy for Non-Preferred subcutaneous or oral products must be supported with verification: either verification in prescription claims history (preferred) or, if 130 days of claims history is unavailable, verification by the prescriber. Claims history must show the patient received the Non-Preferred product for the specified period (90 or 120 days) within a 130-day lookback period. If prescriber verification is used, it must also confirm the product was obtained via paid claims (no samples/coupons).

Approval Duration: 1 year for continuation unless noted otherwise
Verification in prescription claims history required when ≥130 days of claims available
If claims history unavailable, prescriber verification required and must confirm paid-claims (no samples/coupons)

Documentation Required

Verification of Ongoing Therapy

Verification of ongoing therapy and prescription claims history. For continuation requests, verify ongoing therapy through claims history or prescriber attestation as specified above. Verification must document the required treatment duration (90 or 120 days) within the 130-day lookback when claims are used. The prescriber must attest to duration and that therapy was obtained via paid claims when claims data are insufficient.

Verification of ongoing therapy
Verification of prescription claims history for continuation (130-day lookback / 90-120 day treatment window)

Documentation Required

Documentation of Prior Trials

Documentation requirements for prior trials. Written documentation of prior biologic and/or JAK inhibitor trials is required when noted in criteria. Acceptable documentation includes chart notes, prescription claims records, and/or prescription receipts and must include patient-identifying information. Trials of more than one product in the same biologic class (e.g., multiple adalimumab products or multiple ustekinumab products) may count as one Preferred Product trial as specified in definitions and footnotes. Footnote indications for juvenile idiopathic arthritis (JIA) and maintenance dosing requirements must be followed where applicable.

Documentation of prior biologic/JAK trials required [documentation required] when noted
Acceptable documentation: chart notes, prescription claims, receipts (must include patient identifiers)
Trials of multiple products in the same class may count as one Preferred Product (see definitions/footnotes)
Footnote indications for JIA and maintenance dosing apply

Step Therapy

Step Therapy / Alternative Product Review

Step therapy / Alternative product review. Step therapy trial requirements apply per the Step 1 / Step 2a / Step 2b / Step 3a logic in the Preferred/Non-Preferred product tables. When criteria are not met, the program may offer review of Step 1 or Step 2a (Preferred) products or alternative products. Some Non-Preferred approvals are directed to one or more specific Step 1 or Step 2 products; others require documentation of trials of two Step 1 or 2a products. When criteria are unmet, clinicians may request review for alternative products; the reviewer will consider trials already completed and class-counting rules.

Step therapy trial requirements apply (Step 1 → Step 2a → Step 3 as specified)
Offer review of Step 1 or Step 2a / Preferred Products when criteria are not met
Trials of multiple products in same class may count as a single Step 1 trial per definitions

Operational notes: Document prior trials using chart notes, prescription claims records, and/or receipts; include patient identifiers. The paid-claims exception requires confirmation that prior therapy was obtained through paid claims—samples/coupons do not qualify. Counting rules for trials across formulations and multiple products in the same class are specified in definitions; follow JIA and maintenance dosing footnotes where applicable.

Initial Therapy Criteria (by product/indication)

General Program / Prior Authorization Requirements

General program and prior authorization overview: standard Prior Authorization (PA) program rules apply to all products in this policy. Trials of Preferred Product(s) per the step table are required, when clinically appropriate, before approval of Non‑Preferred Products. Trials of multiple products within the same preferred product family (e.g., multiple adalimumab products or multiple ustekinumab products) count as a single preferred trial. Continuation approvals and documentation/verification rules are detailed below.

ALL of the following

Patient meets the applicable standard Medical Mutual of Ohio Prior Authorization Policy criteria for the requested medication (refer to the respective PA policy).
Trials of Preferred Product(s) per the Step Table are required prior to approval of Non‑Preferred Products unless an exception is documented in the criteria below.
A trial of more than one product within the same Preferred product family (for example, multiple adalimumab products or multiple ustekinumab products) will count as a single Preferred product trial.

Continuation Therapy Criteria

Formulary Step Table Logic

Step 1 equals Preferred products for each indication (examples include Enbrel; adalimumab products — see listed biosimilars and NDC guidance; Taltz; Cimzia; Otezla/Otezla XR). Higher steps are Non-Preferred and are directed to trials of lower-step (Step 1/2) products per the step table; specific PA policies for each product/indication define the exact step placement and requirements.

Applicable Codes

Adalimumab products (specified examples / NDC guidance)mixedCovered

NDCs starting with 82009	adalimumab-ryvk NDCs starting with 82009 (Simlandi/other adalimumab biosimilars referenced)
general	Examples listed: Humira, Abrilada, adalimumab-aacf, adalimumab-adaz, adalimumab-adbm, adalimumab-fkjp, adalimumab-aaty, adalimumab-ryvk, Simlandi, Amjevita, Cyltezo, Hadlima, Hulio, Hyrimoz, Idacio, Yuflyma, Yusimry

Products named in policy scope (examples of molecules included in policy)mixed

Olumiant	baricitinib tablets - Eli Lilly
Rinvoq	upadacitinib extended-release tablets - AbbVie
Rinvoq LQ	upadacitinib oral solution - AbbVie
Xeljanz	tofacitinib tablets / oral solution - Pfizer
Xeljanz XR	tofacitinib extended-release tablets - Pfizer
Otezla	apremilast tablets - Amgen
Otezla XR	apremilast extended-release tablets - Amgen
Velsipity	etrasimod tablets - Pfizer
Zeposia	ozanimod capsules - Celgene
Sotyktu	deucravacitinib tablets - BMS

1–10 of 19

1/2

NDCs referenced for adalimumab-ryvkNDC

NDCs starting with 82009

adalimumab-ryvk NDCs referenced in multiple product preference lists

adalimumab-ryvk NDC notationNDC

NDCs starting with 82009

Identifiers for adalimumab-ryvk products

NDCs referenced for specific adalimumab productsNDC

NDCs starting with 82009

adalimumab-ryvk and related referenced adalimumab products (specific NDC prefix cited)

Adalimumab product NDC mentionNDC

NDCs starting with 82009

Adalimumab-ryvk NDCs identified by prefix

Definitions & Notes

Definitions and key terms: Step classifications identify Step 1 as Preferred and higher steps as Non-Preferred directed to lower-step trials. When [documentation required] is noted, prescribers must provide written documentation (chart notes, prescription claims records, receipts) including patient identifiers. A trial of multiple products within the same drug family (e.g., multiple adalimumab products, multiple tocilizumab products, paired formulations such as Xeljanz/Xeljanz XR or Rinvoq/Rinvoq LQ) counts as ONE product trial for prior therapy requirements. The claims verification exception permits prescriber verification when 130 days of claims data are not available, but requires prescriber attestation that the patient received therapy via paid claims (no samples/coupons). Preferred Product / Step 1 Product denotes the designated alternate biologic or small molecule therapies to consider if primary criteria are unmet. Footnote symbols: ^ indicates indication in polyarticular and systemic JIA; # indicates polyarticular JIA; ¥ indicates maintenance dosing only.

Background

Background: this policy governs formulary placement and PA criteria for many biologic and oral targeted therapies used in inflammatory diseases; FDA-approved indications are listed in Appendix A and product-specific PA criteria are maintained in the referenced standard PA policies. The program specifies that, where noted, trials of multiple products of the same class may be counted as a single prior trial for step/exception determinations.

Revision History

Policy Summary

Payermedical mutual - ohio

PolicyNon-Preferred vs Preferred biologic and targeted therapies for inflammatory conditions (rheumatology, dermatology, gastroenterology)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization and document required trials of Preferred/Step 1 products per the respective standard Inflammatory Conditions PA policies.

On This Page

Continuation verification

If at least 130 days of prescription claims history are available, claims history must show the patient received the Non‑Preferred Product for the specified continuous period (90 or 120 days) within a 130‑day lookback period.
[verification in prescription claims history required]
If 130 days of claims history are unavailable, the prescriber must provide verification that the patient received the Non‑Preferred Product for the specified period (90 or 120 days) and that therapy was via paid claims (no samples/coupons used).
[verification by prescriber required]

Documentation supporting prior trials, when required, must include patient identifiers and may include chart notes, prescription claims records, or receipts.

Approval duration: continuation approvals are generally for 1 year unless noted otherwise; when approvals are in months, 1 month = 30 days.

Step Table Logic (Preferred and Non‑Preferred Products)

Step table logic summary (how Step 1 Preferred and Step 2/3 Non‑Preferred interact).

ALL of the following

Step therapy requires trial(s) of Step 1 Preferred product(s) when clinically appropriate before Step 2 or Step 3 Non‑Preferred product approval.
Some Step 2 Non‑Preferred approvals are directed to trial of a specific Step 1 product (e.g., directed to adalimumab or Enbrel); where specified, the directed Step 1 product must be tried and failed or contraindicated.
Step 3 Non‑Preferred products typically require trials of two Step 1 or Step 2a products and may require documentation of why those products were unsuitable. When the criteria state [documentation required], written chart documentation must be provided.
When criteria indicate 'directed to ONE Step 1 Product' that direction must be followed (the member must have tried the named Step 1 agent).
When criteria indicate trials of two Step 1 or 2a products, the trials may be from across product families; document duration and reason for failure/intolerance.

Recommended Exception Criteria — Cimzia

Recommended exception criteria — Cimzia (certified examples by indication). Approvals follow the nested indication-specific requirements below; preserve AND/OR logic for required prior trials and durations.

Cimzia — Indication-specific initial therapy rules

Rheumatoid Arthritis (RA)
- Diagnosis of moderate to severe rheumatoid arthritis documented.
- Trial of one Step 1 Preferred agent (e.g., Enbrel or an adalimumab product) AND one Step 2a product if specified by step table when directed; or two Step 1/2a products if required by Step 3 rules.
  Follow step table direction — may require directed agent trial.
- If used as a Non‑Preferred Step 3 product, provide documentation of trials of two Step 1 or 2a products [documentation required].
Ankylosing Spondylitis (AS)
- Diagnosis of AS documented per standard clinical criteria.
- Trial of Step 1 Preferred agents as required (e.g., Enbrel, adalimumab or Taltz) unless contraindicated.
Non‑radiographic axial spondyloarthritis (nr‑axSpA)
- Diagnosis of nr‑axSpA documented.
- Trial of one Step 1 Preferred product (Cimzia or Taltz are listed as Step 1 options); if directed by step table, try the directed Step 1 product first.
Psoriatic Arthritis (PsA)
- Diagnosis of PsA documented.
- Trial of Step 1 Preferred agents per step table (e.g., Enbrel, adalimumab products, Otezla, Skyrizi SC, ustekinumab SC products, Taltz) unless contraindicated.
Ulcerative Colitis (UC)
- Diagnosis of moderate to severe UC documented.
- Trials of Step 1 Preferred gastroenterology agents per step table (e.g., adalimumab products, Omvoh SC, Skyrizi SC on‑body injector, Tremfya SC, ustekinumab SC products, Velsipity, Zymfentra) are required when clinically appropriate.
- When Cimzia is requested as a Non‑Preferred Step 3 product for UC, documentation of trials of two Step 1 or 2a products is required [documentation required].
Documentation and continuation notes
- For patients continuing Cimzia, use verification in prescription claims history when available (130‑day lookback showing 90 or 120 days of therapy as specified); otherwise prescriber verification is required.
- Provide chart documentation for prior trials when criteria state [documentation required].

Simponi Subcutaneous / Simponi Aria recommended exception criteria

Simponi Subcutaneous / Simponi Aria — recommended exception criteria for multiple indications, including an Ulcerative Colitis initial therapy node with verification specifics. Also includes alternate product review when standard criteria partially met.

Simponi SC / Simponi Aria — Indication groups

Rheumatoid Arthritis (RA)
- Diagnosis of RA documented and clinical rationale for Simponi provided.
- Trial of Step 1 Preferred agents per step table (e.g., Enbrel, adalimumab products) required unless contraindicated or directed otherwise by step logic.
Ankylosing Spondylitis (AS)
- Diagnosis of AS documented.
- Trial of Step 1 Preferred agents required (e.g., Enbrel, adalimumab, Taltz) unless contraindicated.
Psoriatic Arthritis (PsA)
- Diagnosis of PsA documented.
- Trial of Step 1 Preferred agents per step table required unless contraindicated.
Ulcerative Colitis (UC) — Initial Therapy
- Diagnosis of moderate to severe UC documented.
- Verification options for continuation of Simponi SC for UC
  - [verification in prescription claims history required]: At least 130 days of prescription claims history showing Simponi administered for the required period (90 or 120 days) within a 130‑day lookback period.
  - [verification by prescriber required]: When claims history is unavailable, prescriber must verify the patient received Simponi for the required period and that therapy was via paid claims (no samples/coupons).
- If requested as Non‑Preferred, follow Step Table direction; if Step 3 requirements apply, provide documentation of trials of two Step 1 or 2a products [documentation required].
Establishment / Currently receiving Simponi
- For patients currently receiving Simponi (SC or IV), continuation may be approved when prescription claims history or prescriber verification meets the continuation verification rules described in General Program / Prior Authorization Requirements.
Alternate product review when criteria partially met
- If the member partially meets step criteria (for example, trial of one but not two required Step 1/2 products), the request may be reviewed for approval to an alternate product that does meet available documented trials. Prescriber must provide documentation supporting prior trials and rationale for alternate selection [documentation required].

Simponi Subcutaneous - Ulcerative Colitis Initial Therapy

Simponi Subcutaneous — Ulcerative Colitis initial therapy (claims verification specifics emphasized).

ALL of the following

Diagnosis of moderate to severe ulcerative colitis documented in the chart.
Documentation of inadequate response, intolerance, or contraindication to Step 1 Preferred gastroenterology agents as required by the Step Table, unless exception applies.
Verification for patients currently receiving Simponi for UC
- [verification in prescription claims history required]: At least 130 days of pharmacy/medical claims history on file documenting receipt of Simponi for the required period (90 or 120 days) within a 130‑day lookback period.
- [verification by prescriber required]: If 130 days of claims history are not available, prescriber must verify the patient has been receiving Simponi for the specified period and that therapy was via paid claims (no samples or coupons).
If requested as Non‑Preferred per step table requirements, provide required prior trials or documentation of why Step 1/2 agents are unsuitable [documentation required].

Zymfentra - All Conditions

Zymfentra (preferred gastroenterology product) — coverage applies across listed gastrointestinal indications when Step Table requirements are met.

Zymfentra — All Conditions

Indication: Crohn's disease or Ulcerative Colitis
- Diagnosis documented according to standard clinical criteria.
- Use aligns with Step 1 Preferred gastroenterology options in the Step Table; trials of other Step 1 agents per table as clinically appropriate.
Zymfentra is a Step 1 Preferred product for selected gastroenterology indications; requests for continuation should follow the General Program verification rules for claims history or prescriber verification.

Actemra Subcutaneous - Polyarticular Juvenile Idiopathic Arthritis and Rheumatoid Arthritis Initial Therapy

Actemra Subcutaneous — Initial therapy for Polyarticular Juvenile Idiopathic Arthritis (PJIA) and Rheumatoid Arthritis (RA).

ALL of the following

Diagnosis of PJIA or moderate to severe RA documented.
Trials of Step 1 Preferred agents as specified by the Step Table (e.g., Enbrel, adalimumab products) unless contraindicated or directed otherwise by step logic.
For Step 3b direction: when Actemra SC is a Step 3b Non‑Preferred product, the step requires trial of ONE Step 1 product AND Tyenne (tocilizumab SC) per the step table; provide documentation of trials [documentation required].
Provide baseline and monitoring labs as required for tocilizumab use per standard safety guidelines (e.g., hepatic enzymes, CBC).

Actemra Subcutaneous - Patient Currently Receiving Tocilizumab (SC or IV) - Continuation

Actemra Subcutaneous — Continuation for patients currently receiving tocilizumab (SC or IV).

ALL of the following

Patient is currently receiving tocilizumab (SC or IV) with documentation of therapy in the prescription claims history or prescriber verification per General Program rules.
Prescriber documents clinical benefit or stable disease control on tocilizumab and intention to continue therapy.
For continuation approvals, provide verification of prior therapy duration per continuation rules; approvals are typically for 1 year.

Actemra Subcutaneous - Other Conditions

Actemra Subcutaneous — Other conditions (off‑label or alternate indications) follow standard PA criteria and require documentation of clinical rationale and prior treatment trials as applicable.

ALL of the following

Diagnosis and clinical rationale for Actemra use documented in chart notes.
Trials of Preferred agents per Step Table or other appropriate therapies documented; provide chart documentation when criteria state [documentation required].
Continuation requests follow General Program verification rules and usual monitoring documentation.

Tyenne Subcutaneous - Polyarticular Juvenile Idiopathic Arthritis & Rheumatoid Arthritis Initial Therapy

Tyenne Subcutaneous (tocilizumab SC) — PJIA & RA initial therapy rules (when used as a Non‑Preferred product follow step table directions).

ALL of the following

Diagnosis of PJIA or RA documented.
Trial of Step 1 Preferred agents per the Step Table unless contraindicated; when Tyenne SC is designated in step logic as directed to a specific Step 1 product, that product must be tried first.
If Tyenne SC is being requested as a Step 2a/3 product, provide documentation of prior trials per the step table [documentation required].

Kevzara - Rheumatoid Arthritis and Juvenile Idiopathic Arthritis Initial Therapy

Kevzara (sarilumab) — Rheumatoid Arthritis and Juvenile Idiopathic Arthritis initial therapy and continuation rules.

Kevzara — Indications

Rheumatoid Arthritis - Initial Therapy
- Diagnosis of moderate to severe RA documented.
- Trials of Step 1 Preferred agents per Step Table required unless contraindicated; if Kevzara is Step 3, provide documentation of trials of two Step 1 or 2a products [documentation required].
Juvenile Idiopathic Arthritis — Initial Therapy (alternate formulation)
- Diagnosis documented (JIA subtype applicable to sarilumab use).
- If alternate formulation or pediatric dosing is requested, provide supporting dosing rationale and trials of preferred agents per step table; documentation required for step exceptions.
Patient currently receiving Kevzara - Continuation
- Prescription claims history or prescriber verification as per General Program rules confirming prior therapy duration and clinical benefit.
- Continuation approvals generally for 1 year.

Bimzelx (Brodalumab) - Multiple Indications Initial Therapy

Bimzelx (brodalumab) — initial therapy and continuation rules across dermatologic and other indications.

Bimzelx — Initial Therapy and Continuation

Multiple Indications - Initial Therapy
- Diagnosis appropriate for brodalumab therapy (e.g., plaque psoriasis) documented.
- As a Non‑Preferred product, trials of two Step 1 or 2a products are commonly required per Step 3 rules; document prior trials [documentation required].
Patient currently receiving Bimzelx — Continuation
- Prescriber provides claims history verification or prescriber attestation per General Program rules that the patient has been receiving Bimzelx and has clinical benefit.
- Continuation approvals typically granted for 1 year.
Ankylosing Spondylitis, Hidradenitis Suppurativa, nr‑axSpA, Plaque Psoriasis, or Psoriatic Arthritis - Currently Receiving Bimzelx
- For members currently on Bimzelx for these indications, verify prior therapy duration via claims history or prescriber verification as described in the General Program section; provide documentation of benefit.

Ankylosing Spondylitis, Non‑Radiographic Spondyloarthritis, Plaque Psoriasis - Cosentyx Initial Therapy

Cosentyx (secukinumab) — Ankylosing Spondylitis, nr‑axSpA, Plaque Psoriasis initial therapy and continuation rules.

Cosentyx — Indication nodes

Ankylosing Spondylitis - Initial Therapy
- Diagnosis of AS documented.
- Trial of Step 1 Preferred agents required unless contraindicated; document prior TNF inhibitor or other indicated therapy trials per step table when applicable.
Non‑radiographic Spondyloarthritis (nr‑axSpA) - Initial Therapy
- Diagnosis of nr‑axSpA documented.
- Trial of Step 1 Preferred agents required (Cimzia or Taltz may be Step 1 options); follow step table direction.
Plaque Psoriasis - Initial Therapy
- Diagnosis of plaque psoriasis documented with severity and prior therapy history.
- Trials of Step 1 Preferred dermatology agents required (e.g., adalimumab products, Enbrel, Otezla, Skyrizi SC, Sotyktu, ustekinumab SC products, Taltz, Tremfya) unless contraindicated.
Cosentyx - Patient Currently Receiving Cosentyx (SC or IV)
- Claims history or prescriber verification confirming duration of therapy and clinical benefit per General Program rules.
- Continuation approvals typically for 1 year.

Siliq - Plaque Psoriasis - Initial Therapy

Siliq (brodalumab) — plaque psoriasis initial therapy and continuation.

Siliq — Plaque Psoriasis nodes

Plaque Psoriasis - Initial Therapy
- Diagnosis of plaque psoriasis documented with prior therapy history and severity.
- Trials of Step 1 Preferred dermatology agents per Step Table required; if Siliq is Non‑Preferred Step 3, provide documentation of trials of two Step 1 or 2a products [documentation required].
Siliq - Patient Currently Receiving Siliq
- Prescriber verification or claims history confirming prior therapy duration and clinical benefit required for continuation approvals.

Ilumya - Plaque Psoriasis - Initial Therapy

Ilumya (tildrakizumab) — plaque psoriasis initial therapy and continuation.

Ilumya — Plaque Psoriasis nodes

Plaque Psoriasis - Initial Therapy
- Diagnosis of plaque psoriasis and documentation of disease severity/prior therapies.
- Trials of Step 1 Preferred dermatology agents per Step Table required; if Ilumya is Non‑Preferred Step 3, provide documentation of required trials [documentation required].
Ilumya - Patient Currently Receiving Ilumya
- Provide claims history or prescriber verification per General Program rules to support continuation.

Entyvio (vedolizumab) - Crohn's Disease and Ulcerative Colitis - Initial Therapy

Entyvio (vedolizumab) — Crohn's disease and Ulcerative Colitis initial therapy rules.

ALL of the following

Entyvio - Crohn's Disease and Ulcerative Colitis - Initial Therapy: Diagnosis of moderate to severe Crohn's disease or ulcerative colitis documented; trials of Step 1 Preferred gastroenterology agents per the Step Table are required when clinically appropriate. For Non‑Preferred status or Step 3 requirements, provide documentation of trials of two Step 1 or 2a products [documentation required]. Continuation requests require verification per General Program rules.

Kineret (anakinra) - Rheumatoid Arthritis - Initial Therapy

Kineret (anakinra) — rheumatoid arthritis initial therapy and continuation rules.

Kineret — Rheumatoid Arthritis nodes

Rheumatoid Arthritis - Initial Therapy
- Diagnosis of RA documented with rationale for anakinra use.
- Trials of Step 1 Preferred agents per Step Table required unless contraindicated; if Kineret is Non‑Preferred, provide documentation consistent with step requirements [documentation required].
Rheumatoid Arthritis - Currently Receiving Kineret (Continuation)
- Claims history or prescriber verification supporting prior therapy duration and clinical benefit required for continuation approvals.
Kineret - Other Conditions
- For other indications, provide diagnosis, clinical rationale, and prior therapy documentation; follow General Program verification rules for continuation.

Orencia (subcutaneous & intravenous) - Rheumatoid Arthritis, JIA, Psoriatic Arthritis - Initial Therapy

Orencia (abatacept) — subcutaneous & intravenous initial and continuation criteria for RA, JIA, and PsA.

Orencia — Initial and Continuation

Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Psoriatic Arthritis - Initial Therapy
- Diagnosis documented for RA, JIA, or PsA as applicable.
- Trials of Step 1 Preferred agents per Step Table required unless contraindicated; if Orencia SC/IV is Non‑Preferred, provide required documentation of prior trials when Step 3 rules apply [documentation required].
Rheumatoid Arthritis, JIA, PsA - Currently Receiving Orencia (SC or IV)
- Claims history or prescriber verification per General Program rules confirming prior therapy duration and clinical benefit required for continuation approvals (typically 1 year).

Olumiant - Rheumatoid Arthritis - Initial Therapy

Olumiant (baricitinib) — rheumatoid arthritis initial therapy and continuation criteria.

Olumiant — RA nodes

Rheumatoid Arthritis - Initial Therapy
- Diagnosis of moderate to severe RA documented.
- Trials of Step 1 Preferred agents per Step Table required when clinically appropriate; if Olumiant is Non‑Preferred Step 3, provide documentation of trials of two Step 1 or 2a products [documentation required].
Olumiant - Currently Receiving Olumiant (Continuation)
- Claims history or prescriber verification per General Program rules verifying prior therapy and benefit; continuation approvals typically granted for 1 year.

Rinvoq / Rinvoq LQ - Multiple Indications - Initial Therapy

Rinvoq and Rinvoq LQ (upadacitinib) — multiple indications and continuation rules, including pediatric LQ pathways.

Rinvoq / Rinvoq LQ — Indications and pathways

Multiple Indications - Initial Therapy
- Diagnosis appropriate for requested indication (e.g., RA, PsA, AS, nr‑axSpA, UC where indicated) documented.
- Trials of Step 1 Preferred agents per Step Table are required when clinically appropriate. Some Step 2a/2b directions mandate trial of a specific Step 1 product (e.g., Enbrel, adalimumab, Cimzia) — follow directed trials as specified.
Rinvoq - Currently Receiving Rinvoq (Continuation)
- Claims history or prescriber verification per General Program rules confirming prior therapy duration and clinical benefit.
Rinvoq LQ - Juvenile Idiopathic Arthritis - Initial Therapy
- Diagnosis of JIA documented and dosing rationale for LQ formulation provided.
- When Rinvoq LQ is requested for JIA, follow pediatric-specific step logic and provide documentation of prior trials per step table or follow alternate pathway if noted (Rinvoq LQ - Alternate Pathway).
Rinvoq LQ - Psoriatic Arthritis - Initial Therapy
- Diagnosis of PsA documented; provide prior trial documentation per step table as required.
Rinvoq LQ - PsA / JIA - Currently Receiving Rinvoq/LQ
- Claims history or prescriber verification documenting prior therapy duration and benefit required for continuation.
Rinvoq LQ - Alternate Pathway
- When alternate pathway is permitted for pediatric or other special populations, prescriber must provide supporting clinical rationale and documentation of prior trials or contraindications to standard Step 1/2 agents [documentation required].

Xeljanz / Xeljanz XR / Xeljanz oral solution - Multiple Indications - Initial Therapy

Xeljanz (tofacitinib) products — initial therapy across multiple indications and continuation rules.

Xeljanz / Xeljanz XR / oral solution — Indications

Multiple Indications - Initial Therapy
- Diagnosis appropriate for requested indication (RA, PsA, UC where indicated) documented.
- Trial of Step 1 Preferred agents per Step Table is required when clinically appropriate; directed step requirements (e.g., directed to Enbrel or adalimumab) must be followed when specified.
Xeljanz/XR - Currently Receiving Xeljanz/XR
- Claims history or prescriber verification per General Program rules confirming prior therapy duration and clinical benefit; continuation approvals typically for 1 year.

Otezla / Otezla XR - All Conditions

Otezla (apremilast) — coverage statement for all conditions in Step Table (dermatology indications predominantly Step 1 Preferred).

ALL of the following

Otezla/Otezla XR is listed among Step 1 Preferred agents for multiple dermatology indications (e.g., PsA, Plaque Psoriasis) — follow Step 1 use per table.
Requests for Otezla for other indications should include diagnosis and prior therapy documentation as required by the Step Table.

Velsipity / Zeposia / Sotyktu - All Conditions / Indication-specific

Velsipity, Zeposia, Sotyktu and other small-molecule products — applicability across indications and step logic.

Velsipity / Zeposia / Sotyktu — All Conditions / Indication-specific

Dermatology / Gastroenterology Indications
- When listed as Step 1 Preferred (for example, Velsipity in UC, Sotyktu in psoriasis), these agents should be trialed per Step Table prior to Non‑Preferred agents when clinically appropriate.
- For Zeposia, refer to product-specific policies for MS and UC (Zeposia PSM Policy) and follow any additional step or documentation requirements noted there.
If criteria state alternate product review when standard criteria partially met, prescriber must provide documentation of partial trials and clinical rationale; coverage decisions may consider approval to an alternate product consistent with documented trials.

Alternate product review when criteria partially met

Alternate product review when criteria partially met — operational guidance.

ALL of the following

If a patient has partially met step requirements (for example, completed only one of two required prior trials), the request may be reviewed for approval to an alternate product that aligns with the documented trials and clinical need.
Prescriber must submit documentation of prior trials, reasons for inadequacy/intolerance, and clinical rationale for the alternate product selection [documentation required].
Approvals under alternate review follow the same verification rules for continuation and typical approval durations unless otherwise noted.