Ebglyss — Blue Cross Blue Shield of Illinois

Initial criteria

• Patient is age < 18 years AND does NOT have any FDA labeled contraindications to the requested agent AND has an indication supported in TWO articles from major peer-reviewed journals showing safety and efficacy AND there is support for an age in the patient’s bracket in TWO articles from peer-reviewed journals OR
• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient does NOT have any FDA labeled contraindications AND ONE of the following applies: patient has another FDA labeled indication for the requested agent and route; OR has another indication supported in compendia; OR prescriber has submitted TWO major peer-reviewed articles supporting proposed use as safe and effective

Reauthorization criteria

• Patient has previously been approved for the requested agent through the plan’s Prior Authorization process AND
• ONE of the following applies:
• A. Diagnosis of moderate-to-severe atopic dermatitis AND BOTH of the following: (1) patient has reduction or stabilization from baseline of ONE of: affected body surface area, flares, pruritus/erythema/edema/xerosis/erosions/oozing/lichenification, OR decrease in EASI or IGA score; AND (2) patient will continue standard maintenance therapies
• OR
• B. Patient has a diagnosis other than moderate-to-severe atopic dermatitis AND has had clinical benefit with the requested agent
• If requested agent is Adbry for atopic dermatitis, ONE of the following: patient age < 18 years; OR initiating therapy; OR treated < 16 consecutive weeks; OR treated ≥ 16 weeks AND (if weigh < 100 kg AND achieved clear/almost clear skin → reduce to 300 mg q4w OR has not achieved clear skin and/or support for 300 mg q2w OR weighs ≥100 kg)
• Prescriber is specialist in area (e.g., dermatologist, allergist, immunologist) or consulted one
• Requested agent will NOT be used in combination with another immunomodulatory agent (e.g., TNF inhibitor, JAK inhibitor, IL-4 inhibitor) OR combination use is supported by prescribing info and clinical trials/guidelines
• Patient does NOT have any FDA labeled contraindications to requested agent

Approval duration

12 months