biologic immunomodulator agents — Blue Cross Blue Shield of Illinois

Initial criteria

• The patient has ONE of the following: tried and had an inadequate response to TWO different NSAIDs used in AS after at least a 4‑week total duration OR tried and had an inadequate response to ONE NSAID after at least a 4‑week duration and intolerance or hypersensitivity to ONE additional NSAID OR has intolerance or hypersensitivity to TWO different NSAIDs
• OR has an FDA‑labeled contraindication to ALL NSAIDs used in AS OR has medication history indicating use of another biologic immunomodulator agent that is FDA‑labeled or supported in compendia for AS

Approval duration

12 months