Highlights

• Yes, they are oral, but we do not have a contract for the JAK inhibitors, so our two preferred agents are Enbrel and Humira. So, our prior authorization criteria to get to a JAK inhibitor require intolerance or failure, or a medical contraindication to an anti-TNF before we approve a JAK inhibitor.
• Well, I do not know if it is a minimum standard, but we do look at efficacy, safety, and then cost, and those are all the prior things that we evaluate. But I would not say that there is a minimum standard, and we do not have a lot of comparative data between the agents. So, nobody has ever been able to differentiate one TNF from another in terms of differential efficacy, and there is not a lot of difference in safety, and even the guidelines generically mention TNF, not a specific agent. So, it really boils down to which agents can we contract for.
• Cost becomes a big factor in this category now, because we have lots of TNFs, we have lots of other agents out there that can be used in RA, so we wind up working at the comparative cost, and we look at the market leader, because it does not do anybody any good to contract for a drug that is not the market leader, that does not have any market share, you can get it cheap but if most people are on something else, I mean what is the point?