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The Policy VaultThe Policy Vault

apremilast tab er — Blue Cross Blue Shield of Kansas

Behçet’s disease (BD)

Initial criteria

  • 1. The requested agent is eligible for continuation of therapy AND ONE of the following: - The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR - The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed.
  • 2. If not continuation of therapy, BOTH of the following must be met:
  • 1. ONE of the following diagnoses:
  • A. Active psoriatic arthritis (PsA) AND ONE of the following: - Has tried and had an inadequate response to ONE conventional agent (i.e., cyclosporine, leflunomide, methotrexate, sulfasalazine) used in the treatment of PsA after at least a 3‑month duration of therapy OR - Has an intolerance or hypersensitivity to ONE conventional agent used in the treatment of PsA OR - Has an FDA‑labeled contraindication to ALL conventional agents used in the treatment of PsA OR - Medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of PsA.
  • B. Plaque psoriasis (PS) AND BOTH of the following: - If pediatric, age ≥ 6 years AND moderate to severe plaque psoriasis AND weight ≥ 20 kg. - ONE of the following: • Has tried and had an inadequate response to ONE conventional agent (i.e., acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA [phototherapy], tacrolimus, tazarotene, topical corticosteroids) used in the treatment of PS after at least a 3‑month duration of therapy OR • Has an intolerance or hypersensitivity to ONE conventional agent used in the treatment of PS OR • Has an FDA‑labeled contraindication to ALL conventional agents used in the treatment of PS OR • Medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of PS.
  • C. Behçet’s disease (BD) AND ALL of the following: - The patient has active oral ulcers associated with BD AND - The patient has had ≥ 3 occurrences of oral ulcers in the last 12 months AND - ONE of the following: • Has tried and had an inadequate response to ONE conventional agent (i.e., topical oral corticosteroids [i.e., triamcinolone acetonide oral paste], colchicine, immunosuppressants) used in the treatment of BD OR • Has an intolerance or hypersensitivity to ONE conventional agent used in the treatment of BD OR • Has an FDA‑labeled contraindication to ALL conventional agents used in the treatment of BD.