Otezla — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) Continuation of therapy — patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed; OR (B) New start criteria as below
• For active psoriatic arthritis (PsA): ONE of the following: (1) Patient has stage four advanced/metastatic cancer and requested agent used to treat the cancer or associated condition with use consistent with best practices, peer-reviewed evidence and FDA approval; OR (2) Patient has tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after ≥3 months; OR (3) Has intolerance/hypersensitivity to ONE conventional agent; OR (4) Has FDA-labeled contraindication to ALL conventional agents; OR (5) Medication history indicates use of another biologic immunomodulator FDA-labeled or compendia-supported for PsA
• For plaque psoriasis (PS): (1) Diagnosis of mild to severe plaque psoriasis in adult OR patient age ≥6 years with moderate to severe plaque psoriasis and weight ≥20 kg; AND ONE of the following: (A) Stage four advanced/metastatic cancer criteria and best practices consistent with FDA approval; OR (B) Has tried and had inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA [phototherapy], tacrolimus, tazarotene, topical corticosteroids) after ≥3 months; OR (C) Has intolerance/hypersensitivity to ONE conventional agent; OR (D) Has FDA labeled contraindication to ALL conventional agents; OR (E) Medication history indicates use of another biologic immunomodulator agent FDA labeled or compendia supported for PS
• For Behcet’s disease (BD): ALL of the following: (1) Active oral ulcers associated with BD; AND (2) ≥3 occurrences of oral ulcers in past 12 months; AND ONE of the following: (A) Stage four advanced/metastatic cancer criteria and best practices consistent with FDA approval; OR (B) Has tried and had inadequate response to ONE conventional agent (topical oral corticosteroids such as triamcinolone dental paste, colchicine); OR (C) Has intolerance/hypersensitivity to ONE conventional agent; OR (D) Has FDA labeled contraindication to ALL conventional agents; OR (E) Medication history indicates use of another biologic immunomodulator agent FDA labeled or compendia supported for BD