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 (6‑mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, 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 used in UC OR has severely active ulcerative colitis OR has medication history indicating use of another biologic immunomodulator agent that is FDA‑labeled or supported in compendia for UC

Approval duration

12 months