IL-4 inhibitors — Blue Cross Blue Shield of Illinois

Initial criteria

• Presence of ≥20 firm, nodular lesions AND pruritus lasting ≥6 weeks AND history/signs of repeated scratching, picking, or rubbing
• AND ONE of the following: (A) BOTH of the following: 1. Patient has stage four advanced metastatic cancer and requested agent used to treat cancer or associated condition AND 2. Use consistent with best practices and FDA approved OR (B) ONE of the following: 1. Tried and had inadequate response to ONE at least medium-potency topical corticosteroid after ≥2 weeks OR 2. Intolerance or hypersensitivity to ONE medium-potency topical corticosteroid OR 3. FDA labeled contraindication to ALL medium-, high-, and super-potency topical corticosteroids OR 4. Medication history indicates use of another biologic immunomodulator agent FDA labeled or supported in compendia for treatment of PN

Approval duration

6 or 12 months per plan