Xeljanz XR — Blue Cross Blue Shield of Illinois

systemic sclerosis associated interstitial lung disease

Initial criteria

Prescriber is a specialist in the relevant area of the patient’s diagnosis or has consulted with one
Patient will not use requested agent with another immunomodulatory agent OR if used in combination, BOTH: the prescribing information does not limit such use AND there is supporting evidence (clinical trials, phase III studies, or guidelines)
Patient does not have any FDA-labeled contraindications to the requested agent
If agent labeling requires latent tuberculosis testing, patient has been tested and treated if positive OR labeling does not require testing

Request is not for Olumiant or Actemra use for COVID-19 in hospitalized adults on oxygen/ventilation/ECMO
If alopecia areata is requested, condition must not be excluded from benefit
Patient was previously approved for the requested agent through plan’s prior authorization
For atopic dermatitis: patient had clinical benefit and will continue standard maintenance therapy
For polymyalgia rheumatica: patient had clinical benefit and, if Kevzara, no neutropenia (ANC <1000/mm^3), thrombocytopenia (platelets <100,000/mm^3), or AST/ALT >3× ULN
For other diagnoses: patient had clinical benefit with the requested agent
Prescriber is specialist in relevant area or has consulted with such
Agent not used in prohibited combination, or combination supported per prescribing information and evidence
Requested agent is eligible for continuation OR meets step therapy per indication (Step 1a,1b,2,3a,3b,3c rules as outlined)
If Cosentyx 300 mg maintenance: meets dosing and response conditions per indication
If Tremfya 200 mg: diagnosis is Crohn’s disease or ulcerative colitis
If Omvoh 300 mg maintenance: diagnosis is Crohn’s disease
If Actemra for SSc-ILD: requested as syringe, not ACTpen
Patient has no FDA-labeled contraindications

12 months (except Rinvoq for AD 6 months; Siliq for PS 16 weeks; Xeljanz/Xeljanz XR for UC induction 16 weeks)