Opzelura — Blue Cross Blue Shield of Kansas

nonsegmental vitiligo

Initial criteria

Patient’s body surface area (BSA) ≤ 10%
ONE of the following based on affected area:
A. Vitiligo impacting areas OTHER THAN face, neck, axillary, or groin: ONE of (1) tried and had inadequate response to at least a medium‑potency topical corticosteroid after ≥ 2 weeks of therapy OR (2) intolerance or hypersensitivity to a medium‑potency topical corticosteroid OR (3) FDA‑labeled contraindication to ALL medium‑, high‑, and super‑potency topical corticosteroids
B. Vitiligo on face, neck, axillary, or groin: ONE of (1) tried and had inadequate response to at least a medium‑potency topical corticosteroid after ≥ 2 weeks OR (2) tried and had inadequate response to a topical calcineurin inhibitor OR (3) intolerance or hypersensitivity to a medium‑potency topical corticosteroid OR a topical calcineurin inhibitor OR (4) FDA‑labeled contraindication to ALL medium‑, high‑, and super‑potency topical corticosteroids AND ALL topical calcineurin inhibitors
Patient’s age is within FDA labeling for indication OR there is support for use in the patient’s age
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

6 months