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The Policy VaultThe Policy Vault

Zeposia — Blue Cross Blue Shield of Alabama

multiple sclerosis (MS)

Preferred products

  • Adalimumab-aaty
  • Adalimumab-adaz
  • Hadlima
  • Humira
  • Simlandi
  • Selarsdi
  • Stelara
  • Steqeyma
  • Yesintek

Initial criteria

  • The requested agent is eligible for continuation of therapy AND ONE of the following: - The patient has been treated with the requested agent within the past 90 days OR - The prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed
  • OR BOTH of the following: - The patient has a diagnosis of multiple sclerosis (MS) AND - The patient will NOT be using the requested agent in combination with another MS disease modifying agent (DMA)
  • OR The patient has a diagnosis of moderately to severely active ulcerative colitis (UC) AND ALL of the following: - ONE of the following: • The patient has tried and had an inadequate response to ONE conventional agent (6-mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) used in UC for at least 3 months OR • The patient has severely active ulcerative colitis OR • The patient has an intolerance or hypersensitivity to ONE conventional agent used for UC OR • The patient has an FDA labeled contraindication to ALL conventional agents used for UC OR • The patient’s medication history indicates use of another biologic immunomodulator agent labeled/supported for UC AND ONE of the following: • The patient has tried and had an inadequate response to TWO Step 1 immunomodulatory agents (see Immunomodulatory Agent Step table) OR • The patient has an intolerance or hypersensitivity to at least TWO Step 1 immunomodulatory agents OR • The patient has an FDA labeled contraindication to ALL Step 1 immunomodulatory agents AND The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) AND If FDA labeled indication: • The patient’s age is within FDA labeling OR there is support for use for patient’s age for the requested indication AND The prescriber is a specialist in the area of diagnosis (e.g., gastroenterologist) or has consulted with one AND The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND ONE of the following: - BOTH of the following: • The patient has a diagnosis of multiple sclerosis (MS) AND The patient will not be using the requested agent in combination with another MS disease modifying agent (DMA) OR - The patient has a diagnosis of ulcerative colitis AND ALL of the following: • The patient has had clinical benefit with the requested agent AND The prescriber is a specialist or has consulted with one in the area of the diagnosis AND The patient does not have any FDA labeled contraindications to the requested agent AND The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors)

Approval duration

12 months