ustekinumab products — Blue Cross Blue Shield of Illinois

psoriasis

Preferred products

Patient received an ustekinumab IV product for induction therapy OR is new to therapy and will receive an ustekinumab IV product for induction therapy
If the patient has an FDA labeled indication, then ONE of the following: patient’s age is within FDA labeling for the requested indication OR there is support for use for the patient’s age for the requested indication
If ustekinumab 90 mg product is requested, then ONE of: (A) diagnosis of psoriasis AND weight >100 kg OR (B) dual diagnosis of psoriasis and psoriatic arthritis AND weight >100 kg OR (C) diagnosis of Crohn’s disease or ulcerative colitis
Prescriber is a specialist in the area of the diagnosis (rheumatology, gastroenterology, dermatology) or has consulted with such a specialist
ONE of the following regarding concomitant therapy: (A) patient will NOT be using another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) patient will be using in combination AND BOTH of the following: prescribing information does NOT limit combination use AND documentation supports combination therapy
Patient does NOT have any FDA labeled contraindications to the requested agent
Patient has been tested for latent tuberculosis and if positive has begun therapy for latent TB
Use supported by AHFS, DrugDex (1, 2a, or 2b) or NCCN (1, 2a, or 2b) evidence

Patient previously approved for the requested agent through the plan’s Prior Authorization process (renewal must be for same strength)
Patient has had clinical benefit with the requested agent
ONE of the following regarding preferred agent use: (A) requested agent is a preferred agent OR (B) inadequate response or intolerance to required number of preferred agents as described: 3 preferred after ≥6 months each, or 2 after ≥6 months plus intolerance to one, or 1 after ≥6 months plus intolerance to two, or intolerance to 3 preferred agents, or (C) FDA labeled contraindication to all preferred agents not expected to occur with requested agent
Prescriber is a specialist or has consulted with specialist in the area of diagnosis
ONE of the following regarding concomitant therapy: (A) patient will NOT be using the requested agent in combination with another immunomodulatory agent OR (B) combination use allowed, with both prescribing information not limiting and supporting evidence provided
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months