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Ohtuvayre — Blue Cross Blue Shield of Illinois

other compendia supported indication

Initial criteria

  • ALL of the following:
  • 1. BOTH of the following:
  • A. ONE of the following:
  • 1. The patient has a diagnosis of chronic obstructive pulmonary disease (COPD) AND ALL of the following:
  • A. The patient's diagnosis was confirmed by spirometry with a post-bronchodilator FEV1/FVC ratio < 0.7 AND
  • B. The patient has a post-bronchodilator FEV1 between 30% to 70% predicted AND
  • C. ONE of the following:
  • 1. The patient has a modified Medical Research Council (mMRC) dyspnea score ≥ 2 OR
  • 2. The patient has a COPD Assessment Test (CAT) score ≥ 10 AND
  • D. ONE of the following:
  • 1. The patient is currently being treated with a LABA + LAMA combination with or without an inhaled corticosteroid (ICS) OR
  • 2. The patient has an intolerance or hypersensitivity to a LABA + LAMA combination OR
  • 3. The patient has an FDA labeled contraindication to ALL LABA + LAMA combinations OR
  • 2. The patient has another FDA labeled indication for the requested agent
  • B. 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 using the requested agent for the patient’s age for the requested indication AND
  • 2. If the patient has a diagnosis of COPD, the patient will continue COPD control therapy (e.g., LABA, LAMA, ICS) in combination with the requested agent AND
  • 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., allergist, immunologist, pulmonologist) or has consulted with such a specialist AND
  • 4. The patient does NOT have any FDA labeled contraindications to the requested agent
  • The requested agent will also be approved when the following are met:
  • 1. The member resides in Ohio AND
  • 2. The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following:
  • A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • B. ONE of the following:
  • 1. The patient has another FDA labeled indication for the requested agent and route of administration OR
  • 2. The patient has another indication supported in compendia for the requested agent and route of administration OR
  • 3. The prescriber has submitted TWO peer-reviewed journal articles (major journals such as JAMA, NEJM, Lancet) supporting the proposed use as generally safe and effective.

Reauthorization criteria

  • ALL of the following:
  • 1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • 2. ONE of the following:
  • A. The patient has a diagnosis of COPD AND BOTH of the following:
  • 1. The patient has had a decrease in exacerbations and/or dyspnea with the requested agent AND
  • 2. The patient will continue COPD control therapy (e.g., LABA, LAMA, ICS) in combination with the requested agent OR
  • B. The patient has a diagnosis other than COPD AND has had clinical benefit with the requested agent AND
  • 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., allergist, immunologist, pulmonologist) or has consulted with such a specialist AND
  • 4. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL); others: initial 6 months, renewal 12 months