Vimovo — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following:
• A. For Duexis or ibuprofen-famotidine requests: patient has diagnosis of rheumatoid arthritis OR osteoarthritis
• B. For Vimovo or naproxen-esomeprazole requests: patient has osteoarthritis OR rheumatoid arthritis OR ankylosing spondylitis in adults OR juvenile idiopathic arthritis in adolescents weighing ≥ 38 kg
• C. For Yosprala or aspirin-omeprazole requests: patient has indication listed under Yosprala criteria above
• AND patient has ≥1 of the following risk factors for NSAID-induced GI ulcer: age ≥65 years (≥55 years for Yosprala), prior history of peptic/gastric/duodenal ulcer, history of NSAID-related ulcer, history of clinically significant GI bleeding, untreated or active H. pylori gastritis, concurrent use of oral corticosteroids, anticoagulants, or antiplatelets
• AND if patient has an FDA labeled indication: age is within labeling OR supported for use in patient's age
• AND ONE of the following holds:
• A. Support why individual ingredients as separate dosage forms are not clinically appropriate for patient OR
• B. Patient has stage 4 advanced metastatic cancer and agent used to treat cancer or associated condition (with documentation) OR
• C. Patient is currently treated and stable on requested agent (with chart notes) OR
• D. Patient tried and had inadequate response to individual ingredients as separate dosage forms (with chart notes) OR
• E. Individual ingredients were discontinued due to lack of efficacy/effectiveness/adverse event (with chart notes) OR
• F. Patient has intolerance or hypersensitivity to individual ingredients (with chart notes) OR
• G. Patient has FDA labeled contraindication to individual ingredients (with chart notes) OR
• H. Individual ingredients expected to be ineffective or cause adherence or safety issues (with chart notes) OR
• I. Individual ingredients not in best interest of patient based on medical necessity (with chart notes) OR
• J. Patient tried another drug in same class or mechanism as ingredients and discontinued due to lack of efficacy or adverse event (with chart notes)
• AND patient does NOT have any FDA labeled contraindications to requested agent
• Length of approval: 12 months
• For Ohio members under Fully Insured or HIM Shop (SG) plans: approval if patient has no contraindications AND either FDA labeled indication or compendia-supported indication or ≥2 peer-reviewed journal articles supporting use

Approval duration

12 months