nemolizumab-ilto — Blue Cross Blue Shield of Illinois

Initial criteria

• Request will be approved when ONE of the following sets of criteria is met:
• 1. For BCBS MT Fully Insured or MT HIM members:
• • Patient age <18 years AND
• • No FDA labeled contraindications to requested agent AND
• • Indication supported in TWO articles from major peer-reviewed journals (JAMA, NEJM, Lancet) as generally safe and effective (randomized, double blind, placebo controlled; case studies not acceptable) AND
• • Support for use in patient’s age bracket in TWO such articles covering infancy (0–<2 years), childhood (2–11 years), or adolescence (12–17 years) AND
• 2. For Ohio Fully Insured or HIM Shop (SG) members:
• • Member resides in Ohio AND
• • Plan is Fully Insured or HIM Shop (SG) AND
• • No FDA labeled contraindications to requested agent AND
• • ONE of the following:
• – Patient has another FDA labeled indication for the requested agent and route of administration OR
• – Patient has another compendia-supported indication OR
• – Prescriber submitted TWO peer-reviewed journal articles supporting proposed use as generally safe and effective (randomized, double blind, placebo controlled; case studies not acceptable)

Approval duration

same as main program (6–12 months per indication)