Adalimumab (Humira®)
Prior Authorization Criteria for the TRICARE Mail Order Pharmacy (TMOP) and the TRICARE Retail Pharmacy (TRRx) Program

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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.

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)