ruxolitinib phosphate — Blue Cross Blue Shield of Illinois

Initial criteria

• Patient’s affected body surface area (BSA) ≤ 20%
• Patient is NOT immunocompromised
• ONE of the following: patient has tried and had an inadequate response to at least a low-potency topical corticosteroid used in AD after ≥ 4-week duration of therapy OR patient has an intolerance or hypersensitivity to at least a low-potency topical corticosteroid used in AD OR patient has an FDA labeled contraindication to ALL topical corticosteroids used in AD
• ONE of the following: patient has tried and had an inadequate response to a topical calcineurin inhibitor used in AD after ≥ 6-week duration of therapy OR patient has an intolerance or hypersensitivity to a topical calcineurin inhibitor OR patient has an FDA labeled contraindication to ALL topical calcineurin inhibitors used in AD
• BOTH of the following: patient is currently treated with topical emollients and practicing good skin care AND patient will continue topical emollients and good skin care with requested agent
• Prescriber is a specialist (e.g., dermatologist) or has consulted with a specialist
• ONE of the following: patient will NOT use requested agent with another immunomodulatory agent OR combination use supported by prescribing information and clinical evidence
• Patient does NOT have any FDA labeled contraindications

Approval duration

12 months for BCBSIL and BCBSTX; others 3 months