Limited coverage criteria – tofacitinib for psoriatic arthritis

Generic name

tofacitinib

Strength & form

5 mg tablet

Initial

For the treatment of adult patients  ( ≥ 18 years of age) with moderate to severe psoriatic arthritis, when ALL of the following criteria are met:

• Special Authority request is submitted by a rheumatologist

AND

• Patient has cutaneous psoriasis OR family history of cutaneous psoriasis

AND

• All required baseline assessments in applicable domains are submitted¹

AND

• Patient meets either Section A or B below:

Section A: Predominantly peripheral disease

Patient exhibits at least ONE of the following clinical features, despite TWO adequate trials of conventional synthetic disease modifying antirheumatic drugs (csDMARDs) at target dose and duration²:

• Polyarticular (five or more active joints)
• Oligoarticular (one to four active joints) with at least one active joint proximal to, or including, the wrist or ankle
• Dactylitis of two or more digits
• Tenosynovitis or enthesitis refractory to oral nonsteroidal anti-inflammatory drugs (NSAIDs)³ AND steroid injections (steroid injections not required for Achilles tendon)

Section B: Predominantly axial disease

• Patient has inflammatory spinal symptoms with positive imaging findings

AND

• Patient has current Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score of 4 or higher⁴

AND

• Patient has persistent spinal pain despite use of TWO or more NSAIDs³ for a minimum of two weeks each at accepted maximum daily dosages OR has experienced intolerance with NSAID trials

1 year

Renewal

For the continued treatment of adult patients with moderate to severe psoriatic arthritis when ALL of the following criteria are met:

• Special Authority request is submitted by a rheumatologist

AND

• Patient has attained and maintained beneficial clinical effect, defined as an overall 20% or greater improvement from baseline in applicable domains¹