is considered medically necessary to treat moderately to severely active
rheumatoid arthritis (M05.00 – M06.9), polyarticular juvenile idiopathic
arthritis, or systemic juvenile idiopathic arthritis (M08.00 – M08.48) in
patients who have had an inadequate response to at least 2 of the following
products: Humira (Adalimumab), Cimzia (Certolizumab), or Simponi (Golimumab).
subcutaneous dosage form is preferred. If the intravenous dosage form is
requested, documentation must be provided as to why the subcutaneous dosage form
cannot be used.
not been studied and its use should be avoided in combination with biological
DMARDs such as TNF antagonists (Enbrel, Humira, Remicade, and Simponi), IL-1R
antagonists (Kineret), anti-CD20 monoclonal antibodies (Rituxan), and selective
co-stimulation modulators (Orencia) because of the possibility of increased
immunosuppression and increased risk of infection.
Codes Used In This BI: