Methotrexate Auto-injectors
Indications for Prior Authorization
Otrexup (methotrexate injection)
-
For diagnosis of Rheumatoid Arthritis
Indicated in the management of selected adults with severe, active rheumatoid arthritis (RA) (ACR criteria), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs). -
For diagnosis of Polyarticular Juvenile Idiopathic Arthritis
Indicated in the management of children with active polyarticular juvenile idiopathic arthritis (pJIA), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs). -
For diagnosis of Psoriasis
Indicated in adults for the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or after dermatologic consultation. It is important to ensure that a psoriasis “flare” is not due to an undiagnosed concomitant disease affecting immune responses. -
For diagnosis of Limitation of Use
Not indicated for the treatment of neoplastic diseases.
Rasuvo (methotrexate injection)
-
For diagnosis of Rheumatoid Arthritis
Indicated in the management of selected adults with severe, active rheumatoid arthritis (RA) (ACR criteria), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs). -
For diagnosis of Polyarticular Juvenile Idiopathic Arthritis
Indicated in the management of children with active polyarticular juvenile idiopathic arthritis (pJIA), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs). -
For diagnosis of Psoriasis
Indicated in adults for the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or after dermatologic consultation. It is important to ensure that a psoriasis "flare" is not due to an undiagnosed concomitant disease affecting immune responses. -
For diagnosis of Limitation of Use
Not indicated for the treatment of neoplastic diseases.
Reditrex (methotrexate injection)
-
For diagnosis of Rheumatoid Arthritis
Indicated in the management of selected adults with severe, active rheumatoid arthritis (RA) (ACR criteria) who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs). -
For diagnosis of Polyarticular Juvenile Idiopathic Arthritis
Indicated in the management of children with active polyarticular juvenile idiopathic arthritis (pJIA), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs). -
For diagnosis of Psoriasis
Indicated in adults for the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or after dermatologic consultation. It is important to ensure that a psoriasis "flare" is not due to an undiagnosed concomitant disease affecting immune responses. -
For diagnosis of Limitation of Use
Not indicated for the treatment of neoplastic diseases.
Criteria
Rasuvo
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
- One of the following:
- Both of the following:
- Diagnosis of severe, active rheumatoid arthritis AND
- Prescribed by or in consultation with a rheumatologist
- Both of the following:
- Diagnosis of active polyarticular juvenile idiopathic arthritis AND
- Prescribed by or in consultation with a rheumatologist
- Both of the following:
- Diagnosis of severe psoriasis AND
- Prescribed by or in consultation with a dermatologist
- Trial and failure or intolerance to oral methotrexate
Otrexup, Reditrex
Prior Authorization (Initial Authorization)
Length of Approval: 12 Month(s)
- One of the following:
- Both of the following:
- Diagnosis of severe, active rheumatoid arthritis AND
- Prescribed by or in consultation with a rheumatologist
- Both of the following:
- Diagnosis of active polyarticular juvenile idiopathic arthritis AND
- Prescribed by or in consultation with a rheumatologist
- Both of the following:
- Diagnosis of severe psoriasis AND
- Prescribed by or in consultation with a dermatologist
- Trial and failure or intolerance to both of the following:
- Oral methotrexate
- Rasuvo
Otrexup, Rasuvo, Reditrex
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient demonstrates positive clinical response to therapy
P & T Revisions
2025-03-14, 2024-04-03, 2023-10-10, 2023-04-07, 2022-04-22, 2021-03-18, 2020-11-30, 2020-02-20
References
- Otrexup Prescribing Information. Antares Pharma, Inc. Ewing, NJ. November 2022.
- Rasuvo Prescribing Information, Medexus Pharma, Inc. Chicago, IL. December 2024.
- Reditrex Prescribing Information. Cumberland Pharmaceuticals Inc., Nashville, TN. March 2023.
- Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2021;73(7):1108-1123. doi:10.1002/art.41752
- Ringold, S., et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Rheumatol, 71: 846-863.
- Menter, Alan et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. Journal of the American Academy of Dermatology, Volume 82, Issue 6, 1445 - 1486
Revision History
- 2025-03-14: 2025 Annual review. No criteria changes. Background Updates.
- 2024-04-03: 2024 Annual Review. No criteria changes. Background updates.
- 2023-10-10: Patient demonstrates positive clinical response to therapy.
- 2023-04-07: Annual Review, no criteria changes.
- 2022-04-22: 2022 Annual Review, no criteria changes
- 2021-03-18: 2021 UM Annual Review.
- 2020-11-30: Updated guideline to add Reditrex
- 2020-02-20: 2020 UM Annual Review. No changes to criteria.
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