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 ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after at least a 3‑month duration of therapy OR has an intolerance or hypersensitivity to ONE conventional agent used in PsA
• OR has an FDA‑labeled contraindication to ALL conventional agents used in PsA OR has severe active PsA (e.g., erosive disease, elevated inflammatory markers, long‑term damage interfering with function, rapidly progressive) OR has concomitant severe psoriasis (greater than 10% body surface area or involving hands, feet, scalp, face, or genitals, intractable pruritus, serious emotional consequences)
• OR has medication history indicating use of another biologic immunomodulator agent or Otezla that is FDA‑labeled or supported in compendia for PsA

Approval duration

12 months