ozanimod — Blue Cross Blue Shield of Illinois

other FDA labeled indications

Initial criteria

Member resides in Ohio
Plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications to the requested agent
ONE of the following: (a) Patient has another FDA labeled indication for the requested agent and route of administration OR (b) Patient has an indication supported in compendia for the requested agent and route of administration OR (c) Prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
Patient has had clinical benefit with the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis or has consulted with one
For multiple sclerosis: ONE of the following: (a) Patient will NOT use the requested agent with another disease modifying agent (DMA) OR (b) Patient will use the requested agent in combination with Mavenclad (cladribine) AND there is clinical support for this use (e.g., relapse between cycles of Mavenclad)
For ulcerative colitis: ONE of the following: (a) Patient will NOT use the requested agent in combination with immunomodulatory agents (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (b) The requested agent’s prescribing information does NOT limit use with another immunomodulatory agent AND there is support for combination therapy (e.g., guidelines, clinical trials)
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months