Pharmacy Prior Authorization Criteria

Methotrexate Auto-injectors

Indications for Prior Authorization

Otrexup (methotrexate injection)

• For diagnosis of Rheumatoid Arthritis
  Indicated in the management of selected adults with severe, active rheumatoid arthritis (RA) (ACR criteria), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).

• For diagnosis of Polyarticular Juvenile Idiopathic Arthritis
  Indicated in the management of children with active polyarticular juvenile idiopathic arthritis (pJIA), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).

• For diagnosis of Psoriasis
  Indicated in adults for the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or after dermatologic consultation. It is important to ensure that a psoriasis “flare” is not due to an undiagnosed concomitant disease affecting immune responses.

• For diagnosis of Limitation of Use
  Not indicated for the treatment of neoplastic diseases.

Rasuvo (methotrexate injection)

• For diagnosis of Rheumatoid Arthritis
  Indicated in the management of selected adults with severe, active rheumatoid arthritis (RA) (ACR criteria), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).

• For diagnosis of Polyarticular Juvenile Idiopathic Arthritis
  Indicated in the management of children with active polyarticular juvenile idiopathic arthritis (pJIA), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).

• For diagnosis of Psoriasis
  Indicated in adults for the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or after dermatologic consultation. It is important to ensure that a psoriasis "flare" is not due to an undiagnosed concomitant disease affecting immune responses.

• For diagnosis of Limitation of Use
  Not indicated for the treatment of neoplastic diseases.

Reditrex (methotrexate injection)

• For diagnosis of Rheumatoid Arthritis
  Indicated in the management of selected adults with severe, active rheumatoid arthritis (RA) (ACR criteria) who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).

• For diagnosis of Polyarticular Juvenile Idiopathic Arthritis
  Indicated in the management of children with active polyarticular juvenile idiopathic arthritis (pJIA), who have had an insufficient therapeutic response to, or are intolerant of, an adequate trial of first-line therapy including full dose non-steroidal anti-inflammatory agents (NSAIDs).

• For diagnosis of Psoriasis
  Indicated in adults for the symptomatic control of severe, recalcitrant, disabling psoriasis that is not adequately responsive to other forms of therapy, but only when the diagnosis has been established, as by biopsy and/or after dermatologic consultation. It is important to ensure that a psoriasis "flare" is not due to an undiagnosed concomitant disease affecting immune responses.

• For diagnosis of Limitation of Use
  Not indicated for the treatment of neoplastic diseases.

Criteria

Rasuvo

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• One of the following:
• Both of the following:
• Diagnosis of severe, active rheumatoid arthritis
AND
• Prescribed by or in consultation with a rheumatologist
OR
• Both of the following:
• Diagnosis of active polyarticular juvenile idiopathic arthritis
AND
• Prescribed by or in consultation with a rheumatologist
OR
• Both of the following:
• Diagnosis of severe psoriasis
AND
• Prescribed by or in consultation with a dermatologist
AND
• Trial and failure or intolerance to oral methotrexate

Otrexup, Reditrex

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• One of the following:
• Both of the following:
• Diagnosis of severe, active rheumatoid arthritis
AND
• Prescribed by or in consultation with a rheumatologist
OR
• Both of the following:
• Diagnosis of active polyarticular juvenile idiopathic arthritis
AND
• Prescribed by or in consultation with a rheumatologist
OR
• Both of the following:
• Diagnosis of severe psoriasis
AND
• Prescribed by or in consultation with a dermatologist
AND
• Trial and failure or intolerance to both of the following:
• Oral methotrexate
• Rasuvo

Otrexup, Rasuvo, Reditrex

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy

P & T Revisions

2024-04-03, 2023-10-10, 2023-04-07, 2022-04-22, 2021-03-18, 2020-11-30, 2020-02-20

References

1. Otrexup Prescribing Information. Antares Pharma, Inc. Ewing, NJ. November 2022.
2. Rasuvo Prescribing Information, Medexus Pharma, Inc. Chicago, IL. March 2020.
3. Reditrex Prescribing Information. Cumberland Pharmaceuticals Inc., Nashville, TN. March 2023.

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Revision History

• 2024-04-03: 2024 Annual Review. No criteria changes. Background updates.
• 2023-10-10: Patient demonstrates positive clinical response to therapy.
• 2023-04-07: Annual Review, no criteria changes.
• 2022-04-22: 2022 Annual Review, no criteria changes
• 2021-03-18: 2021 UM Annual Review.
• 2020-11-30: Updated guideline to add Reditrex
• 2020-02-20: 2020 UM Annual Review. No changes to criteria.

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