Ambetter Biologic Disease-Modifying Anti-Rheumatic Drugs (DMARDS)

Date: 12/08/20

The availability of Biologic Disease-Modifying Anti-Rheumatic Drugs (DMARDs) is expanding as the U.S. Food and Drug Administration (FDA) is continuing to approve new biologics. Additionally, many current DMARDs are expanding indications. Many of the available Biologic DMARDs have overlapping indications, giving more options to providers and members to treat their condition(s).

Ambetter by Superior HealthPlan is committed to providing appropriate, high-quality and cost-effective drug therapy to members. Therefore, Ambetter has selected certain Biologic DMARDs to be preferred over others based on the indication.

The Ambetter clinical Prior Authorization (PA) criteria for Biologic DMARDs is available on Ambetter’s Clinical, Payment and Pharmacy Policies webpage listed as Biologic DMARDs (HIM.PA.SP60) in the Ambetter (Marketplace) Pharmacy and Biopharmacy section. Please refer to this criterion for preferred agents and non-preferred medications depending on indication.

The following are Biologic DMARDs requiring PA for Ambetter:

• Tocilizumab (Actemra®)
• Certolizumab pegol (Cimzia®)
• Secukinumab (Cosentyx®)
• Etanercept (Enbrel®)
• Vedolizumab (Entyvio®)
• Adalimumab (Humira®)
• Tildrakizumab-asmn (Ilumya™)
• Infliximab-dyyb (Inflectra®)
• Sarilumab (Kevzara®)
• Anakinra (Kineret®)
• Baricitinib (Olumiant®)
• Abatacept (Orencia®)
• Apremilast (Otezla®)
• Infliximab (Remicade®)
• Infliximab-abda (Renflexis™)
• Upadacitinib (Rinvoq™)
• Brodalumab (Siliq™)
• Golimumab (Simponi®, Simponi Aria®)
• Ustekinumab (Stelara®)
• Risankizumab-rzaa (Skyrizi™)
• Ixekizumab (Taltz®)
• Guselkumab (Tremfya®)
• Natalizumab (Tysabri®)
• Tofacitinib (Xeljanz®, Xeljanz® XR)

Additional Information

To view the complete Ambetter 2021 Prescription Drug List, please visit Ambetter’s Pharmacy webpage.

For any questions, please call Ambetter's Pharmacy Department at 1-800-218-7453, ext. 22080.