Opzelura — Blue Cross Blue Shield of Illinois

Initial criteria

• Patient’s affected body surface area (BSA) ≤ 10%
• ONE of the following:
• A. BOTH of the following: prescriber has documented stage four advanced metastatic cancer (for cancer or related condition) AND use consistent with best practices and FDA approval OR
• B. Patient has vitiligo impacting areas OTHER THAN face, neck, axillary, or groin AND ONE of: tried and inadequate response to ≥ medium-potency topical corticosteroid after ≥ 2 weeks OR intolerance or hypersensitivity OR FDA labeled contraindication to ALL medium-, high-, and super-potency topical corticosteroids used in treatment of nonsegmental vitiligo OR
• C. Patient has vitiligo on face, neck, axillary, or groin AND ONE of: tried and inadequate response to medium-potency topical corticosteroid after ≥ 2 weeks OR tried and inadequate response to topical calcineurin inhibitor OR intolerance/hypersensitivity to either medium-potency topical corticosteroid or topical calcineurin inhibitor OR FDA labeled contraindication to ALL medium/high/super-potency topical corticosteroids AND ALL topical calcineurin inhibitors
• Prescriber is a specialist (e.g., dermatologist) or has consulted with a specialist
• ONE of the following: patient will NOT use with another immunomodulatory agent OR combination use supported by labeling and evidence
• Patient does NOT have any FDA labeled contraindications

Approval duration

12 months for BCBSIL and BCBSTX; others 6 months