OH Epic Formulary, available via therapy plan, restricted to:

• Indication: psoriatic arthritis, active ankylosing spondylitis, or non-radiographic axial spondylarthritis
• Service line: Rheumatology
• Formulary location: Outpatient Infusion
• Service location: Outpatient Infusion, Home Infusion
• Patient population: Adult
• Prior authorization required: Yes
• Restriction/criteria of use (all will apply unless specified):
  • No active tuberculosis (TB), Hepatitis B, or Hepatitis C infection-screening is required prior to initiating and during therapy
  • No known active infection
  • Patient is not on concurrent treatment with another IL-inhibitor, TNF-inhibitor, biologic response modifier or other non-biologic immunomodulating agent (e.g., abrocitinib, tofacitinib, baricitinib, upadacitinib, deucravacitinib, etc.)
    • Use with DMARDs and PDE inhibitor (apremilast) is allowable
  • Patient must not have had previous cell depleting therapy (anti-thymoglobulin, alemtuzumab, etc.) within past month
    • Psoriasis Arthritis (PsA)
      • Diagnosis of Psoriasis Arthritis (PsA)
      • For patients with predominantly axial disease, a trial and failure of ONE non-steroidal anti- inflammatory agent (NSAID), unless use is contraindicated.

OR

• • • • For patients with peripheral arthritis, a trial and failure of ONE oral disease-modifying anti rheumatic agent (DMARD) such as methotrexate, azathioprine, sulfasalazine, or hydroxychloroquine, etc., unless use is contraindicated.
    • Ankylosing spondylitis (AS)
      • Diagnosed with active ankylosing spondylitis (AS)
      • Patient had an adequate trial and failure of at least TWO (2) non-steroidal anti-inflammatory agents (NSAIDs), unless use is contraindicated
    • Non-radiographic Axial Spondylarthritis
      • Diagnosed with active axial spondylarthritis
      • Patient had an adequate trial and failure of at least TWO (2) non-steroidal anti-inflammatory agents (NSAIDs) unless use is contraindicated

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