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budesonide oral suspension 2 MG/10ML — Blue Cross Blue Shield of Kansas

eosinophilic esophagitis (EoE)

Initial criteria

  • 1. The patient has a diagnosis of eosinophilic esophagitis (EoE) AND the patient's diagnosis has been confirmed by ALL of the following:
  • A. Chronic symptoms of esophageal dysfunction AND
  • B. Greater than or equal to 15 eosinophils per high-power field on esophageal biopsy AND
  • C. Other causes that may be responsible for or contributing to symptoms and esophageal eosinophilia have been ruled out AND
  • 2. The patient has ONE of the following:
  • A. Has tried and had an inadequate response to ONE standard corticosteroid therapy (i.e., swallowed budesonide nebulizer suspension, swallowed fluticasone from a metered dose inhaler [MDI]) used in the treatment of EoE after at least an 8-week duration of therapy OR
  • B. Has an intolerance or hypersensitivity to ONE standard corticosteroid therapy used in the treatment of EoE that is not expected to occur with the requested agent OR
  • C. Has an FDA labeled contraindication to ALL standard corticosteroid therapies used in the treatment of EoE that is not expected to occur with the requested agent OR
  • D. Has tried and had an inadequate response to ONE proton pump inhibitor (PPI) used in the treatment of EoE after at least an 8-week duration of therapy OR
  • E. Has an intolerance or hypersensitivity to ONE PPI used in the treatment of EoE OR
  • F. Has an FDA labeled contraindication to ALL PPIs used in the treatment of EoE AND
  • 3. If the patient has an FDA labeled indication, then ONE of the following:
  • A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • B. There is support for using the requested agent for the patient’s age for the requested indication AND
  • 4. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., gastroenterologist, allergist, immunologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • 6. ONE of the following:
  • A. The patient has NOT previously been treated with a course of therapy (12 weeks) with the requested agent OR
  • B. The patient has previously been treated with a course of therapy with the requested agent AND there is support for an additional course of therapy with the requested agent

Reauthorization criteria

  • The patient has previously been treated with a course of therapy with the requested agent AND there is support for an additional course of therapy with the requested agent

Approval duration

3 months