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Omvoh 300 mg — Blue Cross Blue Shield of Illinois

atopic dermatitis

Initial criteria

  • Patient has an FDA labeled indication for the requested agent AND no contraindications OR meets Step criteria exceptions (e.g., drug not appropriate, contraindications, adverse reaction, or prior tolerated use).
  • If Omvoh is requested for Crohn’s disease or ulcerative colitis: patient has received or will receive Omvoh IV for induction therapy.
  • If Entyvio is requested for Crohn’s disease or ulcerative colitis: patient has received or will receive at least 2 doses of Entyvio IV therapy.
  • If Skyrizi is requested for Crohn’s disease or ulcerative colitis: patient has received or will receive Skyrizi IV for induction therapy.
  • If Zymfentra is requested for Crohn’s disease or ulcerative colitis: patient has received or will receive an infliximab IV product for induction therapy.
  • If Tremfya is requested for ulcerative colitis: patient has received or will receive Tremfya IV for induction therapy.
  • For Cosentyx 300 mg maintenance dosing: (A) plaque psoriasis ± active PsA with requested dose 300 mg every 4 weeks OR (B) hidradenitis suppurativa with requested dose 300 mg every 4 weeks OR every 2 weeks after inadequate response to q4wk for ≥3 months OR (C) active PsA or ankylosing spondylitis with 300 mg q4wk after inadequate response to 150 mg q4wk for ≥3 months.
  • If Tremfya 200 mg is requested: patient has diagnosis of Crohn's disease or ulcerative colitis.
  • If Omvoh 300 mg is requested as maintenance dosing: patient has diagnosis of Crohn’s disease.
  • If Actemra requested for systemic sclerosis associated interstitial lung disease: request must be for Actemra syringe (ACTpen not approvable).
  • If Kevzara requested for polyarticular juvenile idiopathic arthritis: patient weighs ≥63 kg.
  • If patient has moderate-to-severe atopic dermatitis: (A) currently treated with topical emollients and good skin care AND (B) will continue them with requested agent.
  • Prescriber must be or consult with a specialist corresponding to diagnosis.
  • Requested agent not used concomitantly with another immunomodulatory agent unless labeling does not limit and supporting evidence is provided.
  • Patient tested for latent tuberculosis if required by labeling and therapy started if positive.
  • Length of approval: 12 months (exceptions: Rinvoq for AD 6 months; Siliq for PS 16 weeks; Xeljanz/Xeljanz XR for UC induction 16 weeks).

Reauthorization criteria

  • Request not for Olumiant or Actemra for COVID-19 treatment.
  • Patient previously approved for requested agent through PA process.
  • For moderate-to-severe atopic dermatitis: patient had clinical benefit and will continue standard maintenance therapies (emollients, skin care).
  • For polymyalgia rheumatica: patient had clinical benefit; if Kevzara, lab parameters within limits (no neutropenia, thrombocytopenia, or elevated AST/ALT).
  • For all other diagnoses: patient had clinical benefit with requested agent.
  • Prescriber is or consulted a specialist in relevant specialty.
  • Not used in combination with another immunomodulatory agent unless labeling permits and documented support provided.
  • Requested agent eligible for continuation of therapy (all except Actemra) OR meets step prerequisites not required.
  • Length of approval: 12 months.

Approval duration

12 months