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    Immunomodulators

    Drug - Immunomodulators

    January 2025

    Therapeutic area - Cytokine and CAM Antagonists

    Preferred Nonpreferred
    ENBREL KIT (INJECTION)
    ENBREL MINI CARTRIDGE (SUBCUTANE.)
    ENBREL PEN (INJECTION)
    ENBREL SYRINGE (INJECTION)
    ENBREL VIAL (SUBCUTANE.)
    HUMIRA KIT (INJECTION)
    HUMIRA PEN KIT (INJECTION)
    INFLIXIMAB (INJECTION)
    OTEZLA (ORAL)
    XELJANZ (ORAL)    		 ABRILADA SYRINGE (SUBCUTANE.)
    ABRILADA PEN (SUBCUTANE.)
    ADALIMUMAB-ADAZ SYRINGE (SUBCUTANE.)
    ADALIMUMAB-ADAZ PEN (SUBCUTANE.)
    ADALIMUMAB-ADBM SYRINGE (SUBCUTANE.)
    ADALIMUMAB ADBM PEN (SUBCUTANE.)
    ADALIMUMAB-FKJP SYRINGE (SUBCUTANE.)
    ADALIMUMAB-FKJP PEN (SUBCUTANE.)
    ADALIMUMAB-RYVK AUTOINJECT (SUBCUTANE.)
    AMJEVITA SYRINGE (SUBCUTANE.)
    AMJEVITA AUTOINJECTOR (SUBCUTANE.)
    ACTEMRA PEN (SUBCUTANE.)
    ACTEMRA SYRINGE (SUBCUTANE.)
    ACTEMRA VIAL (INJECTION)
    ARCALYST (SUBCUTANE.)
    AVSOLA (INJECTION) BIMZELX SYRINGE (SUBCUTANE.)
    BIMZELX AUTOINJECTOR (SUBCUTANE.)
    CIMZIA KIT (INJECTION)
    CIMZIA SYRINGE KIT (INJECTION)
    COSENTYX PEN INJECTER (SUBCUTANE.)
    COSENTYX SYRINGE (SUBCUTANE.)
    COSENTYX VIAL (INTRAVENOUS)
    CYLTEZO SYRINGE (SUBCUTANE.)
    CYLTEZO PEN (SUBCUTANE.)
    ENSPRYNG (SUBCUTANEOUS)
    ENTYVIO (INJECTION)
    ENTYVIO PEN (SUBCUTANE.)
    HADLIMA SYRINGE (SUBCUTANE.)
    HADLIMA PUSHTOUCH (SUBCUTANE.)
    HULIO SYRINGE (SUBCUTANE.)
    HULIO PEN (SUBCUTANE.)
    HYRIMOZ SYRINGE(SUBCUTANE.)
    HYRIMOZ PEN (SUBCUTANE.)
    IDACIO SYRINGE (SUBCUTANE.)
    IDACIO PEN (SUBCUTANE.)
    ILARIS (SUBCUTANE.)
    ILUMYA SYRINGE (SUBCUTANE.)
    INFLECTRA VIAL (INTRAVEN.)
    KEVZARA (SUBCUTANE.)
    KINERET (INJECTION) OLUMIANT (ORAL)
    OMVOH PEN (SUBCUTANE.)
    OMVOH SYRINGE (SUBCUTANE.)
    OMVOH VIAL (INJECTION)
    ORENCIA CLICKJECT (SUBCUTANE.)
    ORENCIA SYRINGE (SUBCUTANE.)
    ORENCIA VIAL (INJECTION)
    REMICADE (INJECTION)
    RENFLEXIS (INTRAVEN.)
    RINVOQ ER (ORAL)
    RINVOQ LQ SOLUTION (ORAL)
    SIMLANDI AUTOINJECTOR (SUBCUTANE.)
    SILIQ (SUBCUTANE.)
    SIMPONI ARIA VIAL (INTRAVEN.)
    SIMPONI PEN INJECTOR (INJECTION)
    SIMPONI SYRINGE (INJECTION)
    SKYRIZI (SUBCUTANE.)
    SKYRIZI VIAL (INTRAVEN.)
    SOTYKTU (ORAL)
    SPEVIGO (INTRAVEN.)
    SPEVIGO SYRINGE (SUBCUTANE.)
    STELARA SYRINGE (INJECTION)
    STELARA VIAL (INJECTION)
    TALTZ AUTOINJECTOR (SUBCUTANE.)
    TALTZ SYRINGE (SUBCUTANE.)
    TYENNE VIAL (INTRAVENOUS)
    TYENNE PEN (SUBCUTANE.)
    TYENNE SYRINGE (SUBCUTANE.)
    TOFIDENCE (INTRAVENOUS)
    TREMFYA (SUBCUTANE.)
    UPLIZNA (INTRAVEN.)
    VELSIPITY (ORAL)
    XELJANZ SOLUTION (ORAL)
    XELJANZ XR (ORAL)
    YUFLYMA SYRINGE (SUBCUTANE.)
    YUFLYMA AUTOINJECTOR (SUBCUTANE.)
    YUSIMRY PEN (SUBCUTANE.)
    ZYMFENTRA PEN (SUBCUTANE.)
    ZYMFENTRA SYRINGE (SUBCUTANE.)
    • Preferred drugs will not require prior authorization.
    • Nonpreferred drugs must meet initial approval or renewal criteria before payment.
    • Coverage will not be provided if the patient is using more than one immunomodulator drug or biologic at a time (combination therapy) unless the combination therapy is FDA-approved.
    • If applicable, the nonpreferred immunomodulator prior authorization criteria do not replace the requirement for a clinical prior authorization for a specific drug.
    • The inability or unwillingness of the enrolled pharmacy or provider to order or stock the preferred immunomodulator will not be considered as a basis for requesting a nonpreferred immunomodulator

    Initial approval criteria for nonpreferred immunomodulators:

    • Patient meets the age limit and has the diagnosis described in the FDA-approved label of the requested drug; AND
    • The patient has had a trial of at least two preferred chemically unique drugs within the same drug class on the Preferred Drug List, or a trial of at least one preferred drug within the same drug class if there are not two chemically unique preferred drugs within the same drug class. The use of free goods or pharmaceutical samples will not be considered as meeting any step of the nonpreferred drug prior authorization criteria AND (at least one of the following):
      • The prescriber must provide documentation (for example, pharmacy dispensing record, medication orders in patients’ health record, and so forth) at the time of request showing that:
        • the patient adhered to the previous therapies during the trial(s) AND
        • the trial period was sufficient to allow for a positive treatment outcome, or that the drug was discontinued due to an adverse event OR
      • The patient is currently taking the requested nonpreferred drug and is experiencing a positive therapeutic outcome AND the prescriber provides documentation that switching the patient to a preferred drug is expected to cause harm to the patient, or that the preferred drug would be ineffective OR
      • The preferred drug is contraindicated pursuant to the pharmaceutical manufacturer's prescribing information or, due to a documented adverse event or medical condition, is likely to result in the following
        • cause an adverse reaction OR
        • decrease the ability of the patient to achieve or maintain reasonable functional ability in performing daily activities OR
        • cause physical or mental harm to the patientRenewal criteria for nonpreferred immunomodulators:
    • The patient continues to meet initial approval criteria; OR
    • The patient stabilized on the current regimen will be approved. Stabilization on the current regimen is defined as having the prescription filled at least two times in the past 90 days AND MHCP (either FFS or Managed Care) has paid for the previous two fills or chart notes indicating fill/refill history if patient is new to Medical Assistance and pharmacy claims data is not readily available.
    • Continuation of Therapy overrides are not available to bypass generic or biosimilar substitution

    Quantity limits

    • Quantity limits pursuant to the FDA-approved label will apply

    Billing for immunomodulators:

    • If administered by a healthcare professional, the immunomodulator must be billed as a medical claim

    Questions?

    Provider Call Center 844-575-7887

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