Opzelura (ruxolitinib phosphate cream) — Blue Cross Blue Shield of Alabama

Initial criteria

• Patient’s affected body surface area (BSA) ≤ 20%
• Patient is NOT immunocompromised
• ONE of the following: • Tried and had inadequate response to at least a low-potency topical corticosteroid used in AD after ≥ 4-week duration of therapy • Intolerance or hypersensitivity to at least a low-potency topical corticosteroid used in AD • FDA labeled contraindication to ALL topical corticosteroids used in AD
• ONE of the following: • Tried and had inadequate response to a topical calcineurin inhibitor used in AD after ≥ 6-week duration of therapy • Intolerance or hypersensitivity to a topical calcineurin inhibitor used in AD • FDA labeled contraindication to ALL topical calcineurin inhibitors used in AD
• BOTH of the following: • Currently treated with topical emollients and practicing good skin care • Will continue use of topical emollients and good skin care practices in combination with requested agent
• Prescriber is a specialist in area of diagnosis (e.g., dermatologist) or has consulted with one
• ONE of the following: • Patient will NOT use requested agent with another immunomodulatory agent (TNF, JAK, IL-4 inhibitors) • If used concomitantly, prescribing info does not limit combination use AND clinical support for combination therapy is provided
• Patient does NOT have any FDA labeled contraindications to requested agent

Approval duration

3 months