Skip to content
The Policy VaultThe Policy Vault

Cibinqo — Blue Cross Blue Shield of Kansas

moderate-to-severe atopic dermatitis (AD)

Initial criteria

  • ONE of the following: The requested agent is eligible for continuation of therapy AND ONE of the following: The patient has been treated with the requested agent within the past 90 days (samples not approvable) OR The prescriber states the patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed OR BOTH of the following apply:
  • 1. Diagnosis of moderate-to-severe atopic dermatitis (AD) AND BOTH of the following:
  • - ONE of the following: at least 10% body surface area involvement OR involvement of difficult-to-treat body sites (e.g., hands, feet, face, neck, scalp, genitals/groin, skin folds) OR EASI score ≥16 OR IGA score ≥3 AND
  • - ONE of the following: (A) BOTH of the following: patient has tried and had inadequate response to ONE medium-potency topical corticosteroid for ≥4 weeks OR intolerance/hypersensitivity to ONE OR FDA-labeled contraindication to ALL medium-, high-, super-potency topical corticosteroids; AND patient has tried and had inadequate response to ONE topical calcineurin inhibitor (e.g., Elidel/pimecrolimus, Protopic/tacrolimus) for ≥6 weeks OR intolerance/hypersensitivity OR FDA-labeled contraindication to ALL topical calcineurin inhibitors; OR (B) medication history indicates use of another biologic immunomodulator FDA-labeled or compendia-supported for AD.
  • 2. If another FDA labeled indication for requested agent applies, patient’s age must be within FDA labeling or supported in compendia.
  • 3. If patient has moderate-to-severe AD, patient is currently treated with topical emollients and practicing good skin care AND will continue these while taking requested agent.
  • 4. Patient has been tested for latent tuberculosis (TB); if positive, begun therapy for latent TB.
  • 5. Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted with one.
  • 6. ONE of the following regarding concomitant therapy: (A) requested agent will NOT be used with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) will be used in combination AND BOTH of the following: prescribing information does NOT limit use with another immunomodulator AND support for combination therapy has been provided.
  • 7. Patient does NOT have any FDA labeled contraindications to requested agent.

Reauthorization criteria

  • 1. Patient previously approved for requested agent through plan's Prior Authorization process.
  • 2. Patient has had clinical benefit with requested agent.
  • 3. If diagnosis of moderate-to-severe AD, patient will continue standard maintenance therapies (e.g., topical emollients, good skin care).
  • 4. Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted with one.
  • 5. ONE of the following regarding concomitant therapy: (A) requested agent will NOT be used with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) will be used in combination AND BOTH of the following: prescribing information does NOT limit use with another immunomodulatory agent AND support for combination therapy provided.
  • 6. Patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

initial 6 months; renewal 12 months