IL-4 inhibitors — Blue Cross Blue Shield of Illinois

Initial criteria

• Diagnosis confirmed by ALL of the following: chronic symptoms of esophageal dysfunction AND ≥15 eosinophils per high-power field on esophageal biopsy AND other causes ruled out
• AND ONE of the following: (A) Tried and had inadequate response to ONE standard corticosteroid therapy (budesonide oral suspension, swallowed budesonide nebulizer suspension, or swallowed fluticasone MDI) after ≥8 weeks OR (B) Intolerance or hypersensitivity to ONE standard corticosteroid therapy OR (C) FDA labeled contraindication to ALL standard corticosteroid therapies OR (D) Tried and inadequate response to ONE proton pump inhibitor (PPI) after ≥8 weeks OR (E) Intolerance or hypersensitivity to ONE PPI OR (F) FDA labeled contraindication to ALL PPIs

Approval duration

6 or 12 months per plan