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Otezla — Blue Cross Blue Shield of Alabama

plaque psoriasis (PS)

Initial criteria

  • ONE of the following:
  • The requested agent is eligible for continuation of therapy AND ONE of the following:
  • • The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR the prescriber states such and the patient is at risk if therapy is changed
  • OR BOTH of the following:
  • ONE of the following indication sections:
  • • Psoriatic arthritis (PsA): The patient has a diagnosis of active PsA AND ONE of the following:
  • - Has tried and had an inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, or sulfasalazine) after at least a 3‑month duration of therapy OR
  • - Has an intolerance or hypersensitivity to ONE conventional agent OR
  • - Has an FDA labeled contraindication to ALL conventional agents OR
  • - Patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for PsA
  • • Plaque psoriasis (PS): The patient has a diagnosis of plaque psoriasis AND BOTH of the following:
  • - If the patient is a pediatric patient age ≥ 6 years, then BOTH: the patient has moderate‑to‑severe plaque psoriasis AND weighs at least 20 kg AND
  • - ONE of the following:
  • ▪ Has tried and had an inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA [phototherapy], tacrolimus, tazarotene, topical corticosteroids) after at least 3 months OR
  • ▪ Has an intolerance or hypersensitivity to ONE conventional agent OR
  • ▪ Has an FDA labeled contraindication to ALL conventional agents OR
  • ▪ Patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for PS
  • • Behcet’s disease (BD): The patient has a diagnosis of BD AND ALL of the following:
  • - The patient has active oral ulcers associated with BD AND
  • - The patient has had at least 3 occurrences of oral ulcers in the last 12 months AND
  • - ONE of the following:
  • ▪ Has tried and had an inadequate response to ONE conventional agent (topical oral corticosteroids [e.g., triamcinolone dental paste], colchicine, azathioprine) used in BD OR
  • ▪ Has an intolerance or hypersensitivity to ONE conventional agent used in BD OR
  • ▪ Has an FDA labeled contraindication to ALL conventional agents used in BD OR
  • ▪ Patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for BD
  • • The patient has another FDA labeled indication for the requested agent and route of administration AND the patient's age is within or supported for FDA labeling
  • AND ONE of the following (Agents NOT to be used Concomitantly):
  • - The patient will NOT be using the requested agent in combination with another immunomodulatory agent (TNF, JAK, IL‑4 inhibitors) OR
  • - If using in combination, prescribing information does not limit use and evidence supports combination therapy
  • AND ONE of the following:
  • - The patient has a diagnosis of mild severity plaque psoriasis OR
  • - The prescriber is or has consulted with a specialist (dermatologist, rheumatologist)
  • AND The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • • The patient has been previously approved through plan’s PA process
  • • The patient has had clinical benefit with the requested agent
  • • ONE of the following (Agents NOT to be used Concomitantly): patient will NOT use with another immunomodulatory agent OR if used in combination, it is supported by labeling/guidelines

Approval duration

12 months