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Eohilia — Blue Cross Blue Shield of Alabama

eosinophilic esophagitis (EoE)

Preferred products

  • swallowed budesonide nebulizer suspension
  • swallowed fluticasone from metered dose inhaler (MDI)
  • proton pump inhibitor (PPI)

Initial criteria

  • The patient has a diagnosis of eosinophilic esophagitis (EoE) AND the patient's diagnosis has been confirmed by ALL of the following:
  • - Chronic symptoms of esophageal dysfunction
  • - Greater than or equal to 15 eosinophils per high-power field on esophageal biopsy
  • - Other causes that may be responsible for or contributing to symptoms and esophageal eosinophilia have been ruled out
  • AND the patient has ONE of the following:
  • - Has tried and had an inadequate response to ONE standard corticosteroid therapy (i.e., swallowed budesonide nebulizer suspension, swallowed fluticasone from a metered dose inhaler [MDI]) used in the treatment of EoE after at least an 8-week duration of therapy
  • OR
  • - Has an intolerance or hypersensitivity to ONE standard corticosteroid therapy used in the treatment of EoE that is not expected to occur with the requested agent
  • OR
  • - Has an FDA labeled contraindication to ALL standard corticosteroid therapies used in the treatment of EoE that is not expected to occur with the requested agent
  • OR
  • - Has tried and had an inadequate response to ONE proton pump inhibitor (PPI) used in the treatment of EoE after at least an 8-week duration of therapy
  • OR
  • - Has an intolerance or hypersensitivity to ONE PPI used in the treatment of EoE
  • OR
  • - Has an FDA labeled contraindication to ALL PPIs used in the treatment of EoE
  • AND
  • If the patient has an FDA labeled indication, then ONE of the following: [text continues beyond chunk]