Biologic agents for Crohn's disease - policy criteria

[chantell.reagan]

Based on the popularity of our previous analyses, we extended the review of biologic agents to Crohn’s Disease (CD). The latest treatment guidelines in this therapeutic area were issued by the American Gastroenterolgical Association (AGA) in 2006 (prior to the approval of Humira and Cimzia for CD). According to these guidelines Remicade is positioned after failure of conventional therapy for patients with active and fistulizing CD.

Our analysis of CD policies for TNF-inhibitors (Cimzia, Humira and Remicade) issued by 7 plans showed that most plans do have step therapy requirements for active CD; however, most don’t have any step therapy requirements for fistulizing CD. Also, of note, some plans position Remicade as the first-line anti-TNF agent. For your reference, we previously posted an analysis of Tysabri in CD in October 2008.

The following figure provides a comparative summary of the selected policies (click on the image to enlarge it).


Sources:

Maltz BE and DA Schwartz. Medscape. 2008 Oct. Biologic Therapy for Crohn's Disease: Selecting the Right Patient.

Blue Cross and Blue Shield of Florida. Medical coverage guidelines

The Regence Group. Cimzia policy

The Regence Group. Humira policy

The Regence Group. Remicade policy

Excellus BlueCross BlueShield. Clinical Review Prior Authorization policy

Excellus BlueCross BlueShield. Humira (Crohn’s) policy

Excellus BlueCross BlueShield. Remicade policy

BlueCross BlueShield of Alabama. Cimzia Medicare coverage criteria

BlueCross BlueShield of Alabama. Humira coverage criteria

BlueCross BlueShield of Alabama. TNF Antagonists and Other Biologics for Rheumatologic Diseases: Remicade policy

Wellpoint, NextRx. Cimzia policy

Wellpoint, NextRx. Humira policy

Wellpoint, NextRx. Remicade policy

Atena. Clinical Policy Bulletin: Cimzia

Aetna. Clinical Policy Bulletin: Humira

Aetna. Clinical Policy Bulletin: Remicade

Cigna. Humira Coverage Position

Cigna. Remicade Coverage Position