Indications for Prior Authorization:
- Rheumatoid Arthritis
Patients must meet the following criteria for the indication(s) above:
Rheumatoid Arthritis (moderate to severe)
- Diagnosis of moderate to severe rheumatoid arthritis by Rheumatologist (the prescribing MD does not have to be a rheumatologist) AND
- Inadequate response to one or more Disease Modifying Anti-Rheumatic Drugs (DMARDs): Auranofin (Ridaura), Azathioprine (Imuran), Gold sodium thiomalate (Aurolate), hydroxychloroquine (Plaquenil, methotrexate (Rheumatrex), D-penicillamine (Cuprimine), sulfasalazine (Azulfidine). OR
- Has a medical reason why Methotrexate, Hydroxychloroquine, and Sulfasalazine cannot be used AND
- Patient must fail at least two of the following preferred agents: Humira, Enbrel, Actemra or Xeljanz/XR. Failure is defined as patient not in remission or has clinically significant adverse reaction.
- 100 mg SubQ daily (every other day administration may be considered for RA patients who have severe renal insufficiency or end stage renal disease (defined as creatinine clearance < 30 mL/min, as estimated from serum creatinine levels))
- Initial: 3 months to assess patient’s response
- Renewal: one year if patient has clinical response (less than 2 exacerbations requiring steroid therapy)
Risk of Tuberculosis
- Patients should be evaluated for latent tuberculosis infection with a TB skin test. Treatment of latent tuberculosis infection should be initiated prior to therapy with certolizumab.
Last review date: January 22, 2019