Generic Name / Strength / Form

etanercept

Criteria	Approval Period
1. Treatment of Rheumatoid Arthritis according to established criteria* as prescribed by a rheumatologist	First approval: 1 year Annual renewal: 1 year
2. Treatment of Psoriatic Arthritis according to established criteria* as prescribed by a rheumatologist	First approval: 1 year Annual renewal: 1 year
3. Treatment of Ankylosing Spondylitis according to established criteria* as prescribed by a rheumatologist	First approval: 26 weeks Annual renewal: 1 year

Practitioner Exemptions

• Pediatric rheumatologists for pediatric patients diagnosed with rheumatoid arthritis

Forms

* Click on the appropriate Special Authority Form below for full criteria:

• Adalimumab/Etanercept/Infliximab and Abatacept/Rituximab for Rheumatoid Arthritis-Initial or Switching Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Rheumatoid Arthritis-Annual Renewal (PDF)
• Rheumatoid Arthritis Functional Assessment Form (PDF)
• Adalimumab/Etanercept/Infliximab for Psoriatic Arthritis-Initial Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Psoriatic Arthritis-Renewal Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Ankylosing Spondylitis-Initial Coverage (PDF)
• Adalimumab/Etanercept/Infliximab for Ankylosing Spondylitis-Renewal Coverage (PDF)
• BASDAI (Bath Ankylosing Spondylitis-Disease Activity Index) (PDF)

• Ankylosing Spondylitis coverage becomes effective March 14, 2008.
• Coverage for infliximab for psoriatic arthritis becomes effective March 14, 2008.