Rezurock — Blue Cross Blue Shield of Alabama

chronic graft-versus-host disease (chronic GVHD) after failure of at least two prior lines of systemic therapy

Initial criteria

ONE of the following:
• The patient is eligible for continuation of therapy AND ONE of the following:
– Information has been provided that indicates the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days; OR
– The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed;
OR BOTH of the following:
• The patient has chronic graft-versus-host disease (chronic GVHD); AND
• The patient has failed at least two prior lines of systemic therapy;
AND if the patient has an FDA labeled indication, then ONE of the following:
– The patient’s age is within FDA labeling for the requested indication; OR
– There is support for using the requested agent for the patient’s age for the requested indication;
AND the prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or has consulted with a specialist;
AND the patient does NOT have any FDA labeled contraindications to therapy with the requested agent.

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization Review process;
• The patient has had clinical benefit with the requested agent;
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or has consulted with a specialist;
• The patient does NOT have any FDA labeled contraindications to the requested agent.

12 months