Neighborhood Health Plan RI Enbrel Prior Auth

Indication-specific Coverage Criteria

Indication-specific medical necessity criteria

Covered when ALL of the following are met for the specified indication

Rheumatoid arthritis (adult)

Biomarker evidence: Member has either positive RF or positive anti-CCP OR has been tested for RF, anti-CCP, and CRP and/or ESR (all)
Methotrexate requirement: Member has had an inadequate response to at least a 3-month trial of methotrexate at adequate dosing (>=15 mg/week) OR has intolerance/contraindication to methotrexate

Articular juvenile idiopathic arthritis (>=2 years)

Prior biologic: Member has previously received a biologic or targeted synthetic drug indicated for moderately to severely active articular JIA
Inadequate response to csDMARDs: Member has had an inadequate response to methotrexate or another conventional synthetic drug (e.g., leflunomide, sulfasalazine, hydroxychloroquine) administered at adequate dose and duration
NSAID/IA steroid plus poor outcome risk: Member has had inadequate response to scheduled NSAIDs and/or intra-articular glucocorticoids AND one or more risk factors for poor outcome (involvement of ankle, wrist, hip, sacroiliac joint, TMJ; erosive disease; enthesitis; delay in diagnosis; elevated inflammatory markers; symmetric disease)
High-risk features: Member has risk factors for disease severity and meets one of: high-risk joints involved, high disease activity, or judged high risk for disabling joint disease

Psoriatic arthritis (>=2 years)

PsA initial: Member previously received a biologic/targeted synthetic and either has inadequate response to methotrexate/leflunomide/other conventional synthetic DMARDs administered at adequate dose/duration, OR has intolerance/contraindication to those drugs, OR has enthesitis or predominantly axial disease, OR has severe disease
PsA continuation: Member achieves/maintains positive clinical response evidenced by improvement in swollen/tender joints, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, or CRP from baseline

Ankylosing spondylitis / nr-axSpA (adults)

AS/nr-axSpA initial: Member previously received a biologic/targeted synthetic AND has had an inadequate response to at least two NSAIDs OR has intolerance/contraindication to two or more NSAIDs
AS/nr-axSpA continuation: Member achieves/maintains positive clinical response evidenced by improvement in functional status, total spinal pain, inflammation (e.g., morning stiffness), swollen/tender joints, or CRP from baseline

Plaque psoriasis (>=4 years)

PsO initial: Member previously received a biologic/targeted synthetic AND either has crucial body areas affected OR >=10% BSA affected OR >=3% BSA affected plus inadequate response/intolerance to phototherapy or systemic agents (methotrexate, cyclosporine, acitretin) or clinical reason to avoid those agents
PsO continuation: Member achieves/maintains positive clinical response evidenced by reduction in BSA affected or improvement in signs/symptoms (e.g., itching, redness, flaking, scaling, burning, cracking, pain) from baseline

Reactive arthritis

Reactive arthritis initial: Member previously received a biologic AND has had an inadequate response to methotrexate or sulfasalazine OR has intolerance/contraindication to both
Reactive arthritis continuation: Member achieves/maintains positive clinical response evidenced by low disease activity or improvement in tender/swollen joint counts or pain

Hidradenitis suppurativa

HS initial: Member previously received a biologic indicated for severe, refractory HS AND has had an inadequate response to an oral antibiotic regimen for at least 90 days OR has intolerance/contraindication to oral antibiotics
HS continuation: Member achieves/maintains positive clinical response evidenced by reduction in abscess/inflammatory nodule count, reduced new sinus tracts/scarring, decreased lesion frequency, reduced pain/suppuration, improved relapse frequency, improved quality of life, or improvement on a disease severity assessment tool from baseline

Graft versus host disease (acute and chronic)

GvHD initial: Member has had an inadequate response to systemic corticosteroids OR has intolerance/contraindication to corticosteroids
Chronic GvHD continuation: Member achieves/maintains positive clinical response evidenced by low disease activity or improvement in signs and symptoms

Immune checkpoint inhibitor-related toxicity

Severe cutaneous toxicity: Authorization of 1 month may be granted for Stevens-Johnson syndrome or toxic epidermal necrolysis
ICI inflammatory arthritis: Authorization of 12 months may be granted for moderate or severe immunotherapy-related inflammatory arthritis when member had inadequate response to corticosteroids or a conventional synthetic drug OR has intolerance/contraindication to those therapies

Behcet's disease

Behcet initial: Member previously received Otezla or a biologic AND has had an inadequate response to at least one non-biologic medication for Behcet's disease (e.g., azathioprine, colchicine, cyclosporine, systemic corticosteroids)
Behcet continuation: Member achieves/maintains positive clinical response evidenced by low disease activity or improvement in signs and symptoms

Universal continuation requirement: For all covered indications, continuation of therapy requires documentation that the member achieves or maintains a positive clinical response (low disease activity or improvement in signs/symptoms) as specified per indication

Articular juvenile idiopathic arthritis — Initial authorization

Articular juvenile idiopathic arthritis (JIA) — Initial authorization (members ≥2 years):

JIA initial auth

Inadequate response to csDMARD: Member has had an inadequate response to methotrexate or another conventional synthetic drug (e.g., leflunomide, sulfasalazine, hydroxychloroquine) administered at an adequate dose and duration
NSAID/IA steroid plus poor outcome risk: Member has had an inadequate response to a trial of scheduled NSAIDs and/or intra-articular glucocorticoids AND has one or more risk factors for poor outcome (involvement of ankle, wrist, hip, sacroiliac joint, TMJ; presence of erosive disease or enthesitis; delay in diagnosis; elevated inflammatory markers; symmetric disease)
Risk factors for severe disease: Member has risk factors for disease severity and potentially a more refractory disease course (see Appendix B) and meets one of: high-risk joints involved (e.g., cervical spine, wrist, hip), high disease activity, or judged to be at high risk for disabling joint disease

Articular juvenile idiopathic arthritis — Continuation authorization

Articular juvenile idiopathic arthritis — Continuation authorization (members ≥2 years including new members):

JIA continuation: Authorization of 12 months may be granted when member achieves or maintains a positive clinical response evidenced by low disease activity or improvement in signs/symptoms with improvement in any of the following from baseline: number of joints with active arthritis, number of joints with limitation of movement, or functional ability.

Psoriatic arthritis — Initial and continuation authorization

Psoriatic arthritis (PsA) — Initial and continuation authorization (members ≥2 years):

PsA initial: Authorization of 12 months may be granted when member previously received a biologic or targeted synthetic AND either: has mild to moderate disease with inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD administered at adequate dose/duration; has intolerance/contraindication to those drugs; has enthesitis or predominantly axial disease; OR member has severe disease.

PsA continuation: Authorization of 12 months may be granted for members who achieve or maintain a positive clinical response evidenced by improvement in swollen/tender joints, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, or CRP from baseline.

Ankylosing spondylitis / nr-axSpA — Initial and continuation authorization

Ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA) — Initial and continuation authorization (adults):

AS/nr-axSpA initial: Authorization of 12 months may be granted when member previously received a biologic/targeted synthetic AND has had an inadequate response to at least two NSAIDs OR has intolerance/contraindication to two or more NSAIDs.

AS/nr-axSpA continuation: Continuation authorization may be granted when member achieves or maintains a positive clinical response evidenced by improvement in functional status, total spinal pain, inflammation (e.g., morning stiffness), swollen/tender joints, or CRP from baseline.

Plaque psoriasis — Initial and continuation authorization

Plaque psoriasis (PsO) — Initial and continuation authorization (members ≥4 years):

PsO initial: Authorization of 12 months may be granted when member previously received a biologic/targeted synthetic AND either: crucial body areas are affected; at least 10% BSA is affected; OR at least 3% BSA is affected and the member has had an inadequate response or intolerance to phototherapy or pharmacologic treatment with methotrexate, cyclosporine, or acitretin, or has a clinical reason to avoid those agents.

PsO continuation: Authorization of 12 months may be granted when member achieves or maintains a positive clinical response evidenced by reduction in BSA affected from baseline or improvement in signs/symptoms (e.g., itching, redness, flaking, scaling, burning, cracking, pain).

Reactive arthritis — Initial and continuation authorization

Reactive arthritis — Initial and continuation authorization:

Reactive arthritis initial: Authorization of 12 months may be granted when member previously received a biologic indicated for reactive arthritis AND has had an inadequate response to methotrexate or sulfasalazine OR has intolerance/contraindication to those agents.

Reactive arthritis continuation: Authorization of 12 months may be granted when member achieves or maintains a positive clinical response evidenced by low disease activity or improvement in tender/swollen joint counts or pain.

Hidradenitis suppurativa — Initial and continuation authorization

Hidradenitis suppurativa — Initial and continuation authorization:

HS initial: Authorization of 12 months may be granted when member previously received a biologic indicated for severe, refractory HS AND has had an inadequate response to an oral antibiotic regimen for at least 90 days (e.g., clindamycin, metronidazole, moxifloxacin, rifampin, tetracyclines) OR has intolerance/contraindication to oral antibiotics.

HS continuation: Authorization of 12 months may be granted when member achieves or maintains a positive clinical response evidenced by reduction in abscess/inflammatory nodule count, reduced formation of new sinus tracts and scarring, decreased frequency of inflammatory lesions, reduction in pain or suppuration, improved relapse frequency, improved quality of life, or improvement on a disease severity assessment tool from baseline.

Graft versus host disease — Acute and chronic — Initial and continuation authorization

Graft versus host disease — Acute and chronic — Initial and continuation authorization:

GvHD initial: Authorization of 12 months may be granted for treatment of graft versus host disease when member has had an inadequate response to systemic corticosteroids OR has an intolerance/contraindication to corticosteroids.

Chronic GvHD continuation: Authorization of 12 months may be granted when member using the medication for chronic GvHD achieves or maintains a positive clinical response evidenced by low disease activity or improvement in signs and symptoms.

Immune checkpoint inhibitor-related toxicity — Initial and continuation authorization

Immune checkpoint inhibitor (ICI)-related toxicity — Authorization criteria:

ICI severe cutaneous toxicity: Authorization of 1 month may be granted for Stevens-Johnson syndrome or toxic epidermal necrolysis.

ICI inflammatory arthritis: Authorization of 12 months may be granted for moderate or severe immunotherapy-related inflammatory arthritis when member had an inadequate response to corticosteroids or a conventional synthetic drug (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine) OR has intolerance/contraindication to corticosteroids and a conventional synthetic drug.

Behcet's disease — Initial and continuation authorization

Behcet's disease — Initial and continuation authorization:

Behcet initial: Authorization of 12 months may be granted for members who previously received Otezla or a biologic AND have had an inadequate response to at least one non-biologic medication for Behcet's disease (e.g., azathioprine, colchicine, cyclosporine, systemic corticosteroids).

Behcet continuation: Authorization of 12 months may be granted for members who achieve or maintain a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms.

Rheumatoid arthritis — Continuation authorization

Rheumatoid arthritis (RA) — Continuation authorization (adults including new members):

RA continuation: Authorization of 12 months may be granted for adult members using the requested medication for moderately to severely active RA who achieve or maintain a positive clinical response evidenced by at least 20% improvement from baseline in tender joint count, swollen joint count, pain, or disability.20% improvement

12-month authorization for listed indications

Authorization of 12 months may be granted when the following is met for each indication

General authorization requirement: Member is using the requested medication for the specific indication (chronic graft versus host disease OR Behcet's disease OR immune checkpoint inhibitor-related inflammatory arthritis) AND member achieves or maintains a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms.

Safety screening and concomitant therapy

For all indications the following safety conditions apply

TB screening and infection: Member has documented negative TB test (TST or IGRA) within 12 months if biologic-naïve. If TB screening is positive, further testing must confirm no active disease (e.g., chest x-ray); do not administer medication to members with active TB; if latent TB, TB treatment must be started before initiation.within 12 months

Concomitant biologic/targeted synthetic use: Member cannot use the requested medication concomitantly with any other biologic drug or targeted synthetic drug for the same indication.

Dosing and administration conditions

Approvals may be subject to dosing limits

Dose optimization: Use 50 mg product formulations for dose optimization when possible; exceptions for higher quantities of 25 mg vials allowed for members with a latex allergy or when following FDA-approved weight-based dosing.

All indications that are not listed as FDA-approved or included among recognized compendial uses are considered experimental/investigational and not medically necessary. Requests for such non‑listed indications may be denied.

The policy text in the cited sections does not list explicit categorical exclusions beyond the indication‑specific prior therapy, age, and severity requirements described in the criteria. Specific contraindications or reasons to avoid certain therapies are referenced to appendices (e.g., Appendix A or B) and appear within the indication criteria rather than as standalone exclusions.

Do not administer the requested medication to members with active tuberculosis (TB) infection. For biologic‑naïve persons, documentation of a negative TB test (TST or IGRA) within 12 months is required; if screening is positive, further evaluation (e.g., chest x‑ray) must exclude active disease and latent TB treatment must be initiated prior to therapy.

Use of the medication outside the listed FDA‑approved indications and recognized compendial uses is considered not medically necessary and is treated as experimental/investigational under this policy.

The document does not enumerate specific conditions labeled as not medically necessary beyond the general statements that non‑listed indications are experimental and potential denial when required prior therapy trials (e.g., adequate methotrexate trial or required NSAID trials) are not documented. In practice, requests may be denied if the member has not met those prerequisite therapy requirements.

Concomitant use of the requested medication with any other biologic drug or targeted synthetic agent for the same indication is prohibited. Such concomitant therapy is not allowed and may result in denial of the request.

Policy Identifiers and Key Dosing Values

Policy Identifiermixed

2003-A

Reference/policy number

Methotrexate dosing threshold

Methotrexate dosing threshold>= 15 mg/week

ContextReferenced as 'titrated to at least 15 mg/week' for methotrexate adequacy in RA prior-therapy requirement

ApplicabilityUsed to determine adequate methotrexate dosing when assessing inadequate response for RA and other indications requiring csDMARD trial

Methotrexate trial duration

Methotrexate trial duration>= 3 months

ContextRequired minimum trial duration for methotrexate before deeming inadequate response in RA prior-therapy criteria

Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorization of up to 12 months may be granted for select indications when the indication‑specific clinical criteria and documentation are met. Short‑term (1 month) authorization may be granted for immune checkpoint inhibitor‑related Stevens‑Johnson syndrome or toxic epidermal necrolysis.

12‑month approvals available for: rheumatoid arthritis, articular juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis/non‑radiographic axial spondyloarthritis, plaque psoriasis, hidradenitis suppurativa (severe, refractory), graft versus host disease (acute/chronic as specified), Behcet's disease, immune checkpoint inhibitor‑related inflammatory arthritis, and other listed compendial indications.
1‑month approval for ICI‑related Stevens‑Johnson syndrome or toxic epidermal necrolysis.

Denial Risk

Non‑covered Indications

Requests for indications that are not FDA‑approved or listed in compendial uses (see Compendial Uses) are considered experimental/investigational and are not medically necessary.

Drug Background and Scope

Enbrel (etanercept) is indicated for multiple inflammatory rheumatologic and dermatologic conditions, including moderately to severely active rheumatoid arthritis (RA), polyarticular juvenile idiopathic arthritis (pJIA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), and plaque psoriasis (PsO). The policy also lists select compendial uses (for example, non‑radiographic axial spondyloarthritis, reactive arthritis, hidradenitis suppurativa, Behcet's disease, graft versus host disease, and immune checkpoint inhibitor‑related toxicity) that may be covered when the specified clinical criteria are met.

Terms, Compendial Uses, and Clinical Concepts

Compendial uses

Compendial uses listedNon-radiographic axial spondyloarthritis; oligoarticular juvenile idiopathic arthritis; reactive arthritis; hidradenitis suppurativa (severe, refractory)

Additional compendial usesBehcet's disease; graft versus host disease; immune checkpoint inhibitor–related toxicity

Coverage stanceCompendial uses are considered covered when approval criteria are met; other uses are experimental/investigational

High-risk joints / Crucial body areas

High-risk jointsAnkle, wrist, hip, sacroiliac joint (SIJ), temporomandibular joint (TMJ), cervical spine

Crucial body areas for psoriasisHands, feet, face, neck, scalp, genitals/groin, intertriginous areas

OpenPayer

Enbrel (etanercept) coverage — prior authorization and medical necessity criteria

Indication-specific Coverage Criteria

Policy Identifiers and Key Dosing Values

Authorization, Step Therapy, and Documentation Requirements

Drug Background and Scope

Terms, Compendial Uses, and Clinical Concepts