budesonide oral suspension 2 MG/10ML — Blue Cross Blue Shield of Illinois

Initial criteria

• 1. The patient has a diagnosis of eosinophilic esophagitis (EoE) AND the patient's diagnosis has been confirmed by ALL of the following: A. Chronic symptoms of esophageal dysfunction AND B. ≥ 15 eosinophils per high-power field on esophageal biopsy AND C. Other causes that may be responsible for or contributing to symptoms and esophageal eosinophilia have been ruled out
• 2. The patient has ONE of the following: A. Has tried and had an inadequate response to ONE standard corticosteroid therapy (swallowed budesonide nebulizer suspension or swallowed fluticasone MDI) for at least 8 weeks OR B. Has an intolerance or hypersensitivity to ONE standard corticosteroid therapy used in the treatment of EoE that is not expected to occur with the requested agent OR C. Has an FDA labeled contraindication to ALL standard corticosteroid therapies used in the treatment of EoE that is not expected to occur with the requested agent OR D. Has tried and had an inadequate response to ONE proton pump inhibitor (PPI) used in the treatment of EoE after at least an 8-week duration OR E. Has an intolerance or hypersensitivity to ONE PPI used in the treatment of EoE OR F. Has an FDA labeled contraindication to ALL PPIs used in the treatment of EoE
• 3. If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication OR B. There is support for use for the patient's age for the requested indication
• 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, allergist, immunologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• 5. The patient does NOT have any FDA labeled contraindications to the requested agent
• 6. ONE of the following: A. The patient has NOT previously been treated with a course of therapy (12 weeks) with the requested agent OR B. The patient has previously been treated with a course of therapy with the requested agent AND there is support for an additional course of therapy with the requested agent

Reauthorization criteria

• B. The patient has previously been treated with a course of therapy with the requested agent AND there is support for an additional course of therapy with the requested agent

Approval duration

12 months (BCBSIL, BCBSMT, BCBSTX); 3 months (all other plans)