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Return
to the TRICARE Pharmacy Prior Authorization page
Adalimumab (Humira)
is indicated for reducing the signs and symptoms, inducing major clinical response, slowing the progression of joint damage, and improving physical function in adult patients with moderate to severe rheumatoid arthritis. It is also approved for reducing the signs and symptoms of active arthritis in patients with psoriatic arthritis, and
reducing signs and symptoms in patients with active ankylosing spondylitis.
The use of adalimumab in combination
with other medications that work through the same or a similar mechanism
of action, such as anakinra (Kineret), etanercept (Enbrel), and
infliximab (Remicade), is not well-supported by the clinical literature
and may be associated with increased adverse events.
To limit wastage,
the maximum quantity of adalimumab that will be dispensed at any
one time is 6 weeks supply
(3 packs of 2 syringes) from the TRICARE
Mail Order Pharmacy (TMOP) and 4 weeks supply (2 packs of 2 syringes)
from retail network pharmacies as part of the TRICARE Retail Pharmacy
(TRRx) Program. This does not apply to the Crohn's Disease starter pack, which contains 6 pens to be given over the first 4 weeks of treatment. Prescriptions for the Crohn's Disease starter pack are limited to 1 package (6 pens), with no refills.
The following
criteria were established by the DoD Pharmacy & Therapeutics
(P&T) Committee for adalimumab (Humira) obtained through the
TRICARE Mail Order Pharmacy (TMOP) or retail network pharmacies
as part of the TRICARE Retail Pharmacy (TRRx) Program. The prior
authorization form for adalimumab (Humira) is available on the TRICARE
Pharmacy Prior Authorization page. This prior authorization
does not have an expiration date.
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Prior
Authorization Criteria for Adalimumab Injection (Humira)
- Coverage
provided for the treatment of moderately to severely active
rheumatoid arthritis in patients 18 years of age or older.
- Coverage provided for the treatment of active arthritis in patients with psoriatic arthritis 18 years of age or older.
- Coverage provided for the treatment of active ankylosing spondylitis in patients 18 years of age or older.
- Coverage provided for the treatment of moderately to severely active Crohn's disease following an inadequate response to conventional therapy, loss of response to infliximab (Remicade®), or an inability to tolerate infliximab (Remicade®) in patients 18 years of age or older.
- Coverage
NOT provided for concomitant use with anakinra (Kineret),
etanercept (Enbrel), or infliximab (Remicade).
(Criteria approved
in March 2003 by the DoD Pharmacy & Therapeutics Committee,
amended Nov 2005 & Aug 2006 based on changes in FDA indications)
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