Opzelura — Blue Cross Blue Shield of Kansas

Initial criteria

• Patient’s body surface area (BSA) ≤ 20%
• Patient is NOT immunocompromised
• ONE of the following: (a) tried and had an inadequate response to at least a low‑potency topical corticosteroid after ≥ 4 weeks of therapy OR (b) has intolerance or hypersensitivity to a low‑potency topical corticosteroid OR (c) has an FDA‑labeled contraindication to ALL topical corticosteroids used in treatment of AD
• AND ONE of the following: (a) tried and had an inadequate response to a topical calcineurin inhibitor after ≥ 6 weeks of therapy OR (b) has intolerance or hypersensitivity to a topical calcineurin inhibitor OR (c) has an FDA‑labeled contraindication to ALL topical calcineurin inhibitors used in treatment of AD
• AND BOTH of the following: (a) currently treated with topical emollients and practicing good skin care AND (b) will continue use of topical emollients and good skin care practices in combination with Opzelura
• Prescriber is a dermatologist or has consulted with a dermatologist
• Patient will NOT be using Opzelura with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL‑4 inhibitors) OR submitted evidence supports combination use
• Patient does NOT have any FDA‑labeled contraindications to Opzelura

Approval duration

3 months