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

Initial criteria

• Vitiligo is NOT restricted from coverage under patient’s benefit
• Patient’s affected BSA ≤ 10%
• ONE of the following: • Vitiligo impacting areas OTHER THAN the face, neck, axillary, or groin AND ONE of the following: – Tried and had inadequate response to at least a medium-potency topical corticosteroid used in nonsegmental vitiligo after ≥ 2-week duration of therapy – Intolerance or hypersensitivity to at least a medium-potency topical corticosteroid used in nonsegmental vitiligo – FDA labeled contraindication to ALL medium-, high-, and super-potency topical corticosteroids used in nonsegmental vitiligo • Vitiligo on the face, neck, axillary, or groin AND ONE of the following: – Tried and had inadequate response to at least a medium-potency topical corticosteroid used in nonsegmental vitiligo after ≥ 2-week duration of therapy – Tried and had inadequate response to a topical calcineurin inhibitor used in nonsegmental vitiligo – Intolerance or hypersensitivity to at least a medium-potency topical corticosteroid OR a topical calcineurin inhibitor – FDA labeled contraindication to ALL medium-, high-, and super-potency topical corticosteroids AND ALL topical calcineurin inhibitors used in nonsegmental vitiligo
• If patient has another FDA labeled indication, patient's age is within FDA labeling OR there is support for use for that age
• 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

6 months