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Medical Policy Updates
Notification of Policy Revisions Effective July 1, 2008
(Posted April 1, 2008)
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Abatacept
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New policy developed. Under the "When Covered" section; "Orencia (abatacept) may be medically necessary for the treatment of rheumatoid arthritis when the medical criteria and guidelines shown below are met: 1. The patient has moderate to severe rheumatoid arthritis; and 2. The patient has failed to respond adequately to at least one Tumor Necrosis Factor (TNF) inhibiting drug or is intolerant to all TNF-inhibiting drugs (i.e., Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab); and 3. Orencia (abatacept) may be used alone or in combination with methotrexate." Under the "When Not Covered" section; "1. When the criteria stated above are not met. 2. Orencia (abatacept) should not be used in combination with Tumor Necrosis Factor (TNF) inhibiting drugs or other rheumatoid arthritis biologics including Rituxin (rituximab) or Kineret (anakinra), an interleukin-1 receptor antagonist. 3. Orencia (abatacept) is not covered when used for the treatment of juvenile rheumatoid arthritis, juvenile idiopathic arthritis (JIA), multiple sclerosis, systemic lupus erythematosus, graft versus host disease (GVHD) and other non FDA-approved indications is considered investigational." Senior Medical Director review, 3/20/2008. References added. Notification given April 1, 2008. Policy effective July 1, 2008.
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Infliximab
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Evidence Based Guideline converted to Medical Policy. Additional information provided in "Description" and "Policy Guideline" section. Additional indications added to "When Covered" section; "1.c. when used alone or in combination with Methotrexate to reduce the signs and symptoms of moderate to severe rheumatoid arthritis, rapidly advancing progressive rheumatoid arthritis, or psoriatic arthritis;" and "1.h. mild ulcerative colitis where the patient has inadequate response to conventional treatment such as aminosalicylates, corticosteroids, or immunosuppressants (unless unable to tolerate these drugs)." References added. Senior Medical Director review, 3/20/2008. Notification given April 1, 2008. Policy effective 7/1/2008.
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Rituximab for the Treatment of Rheumatoid Arthritis
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New policy developed. Under the "When Covered" section; "Rituxin (rituximab) may be medically necessary for the treatment of rheumatoid arthritis when the medical criteria and guidelines shown below are met: 1. The patient has moderate to severe rheumatoid arthritis; and 2. The patient has failed to respond adequately to at least one Tumor Necrosis Factor (TNF) inhibiting drug or is intolerant to all TNF-inhibiting drugs (i.e., Remicade (infliximab), Enbrel (etanercept), or Humira (adalimumab); and 3. Rituxin (rituximab) is to be used in combination with methotrexate; and 4. The patient is 18 years old or older. 5. Continued use of Rituxin (rituximab) can only be renewed after 6 months have passed from the last course of treatment and retreatment is necessary to control symptoms." Under the "When Not Covered" section; "1. When the criteria stated above are not met. 2. Rituxin should not be used in combination with TNF-inhibiting drugs." Senior Medical Director review, 3/20/2008. References added. Notification given April 1, 2008. Policy effective 7/1/2008. References added.
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