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Otezla (apremilast) — Blue Cross Blue Shield of Kansas

Behçet’s disease (BD)

Initial criteria

  • Diagnosis of Behçet’s disease AND ONE of the following:
  • • Has had an inadequate response to ONE conventional agent (e.g., topical corticosteroids, colchicine, azathioprine) 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 OR
  • • Has medication history indicating use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of BD OR
  • • Has another FDA labeled indication for the requested agent and route of administration
  • AND ONE of the following:
  • • Patient’s age is within FDA labeling for the requested indication OR
  • • There is support for using the requested agent for the patient’s age for the requested indication OR
  • • Patient has another indication that is supported in compendia for the requested agent and route of administration
  • AND ONE of the following regarding concomitant therapy:
  • • The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR
  • • The patient will be using the requested agent in combination with another immunomodulatory agent AND BOTH of the following are met:
  • – The prescribing information for the requested agent does NOT limit the use with another immunomodulatory agent AND
  • – There is support for the use of combination therapy (submitted copy of clinical trials, phase III studies, or guidelines required)
  • AND ONE of the following:
  • • The patient has a diagnosis of mild severity plaque psoriasis OR
  • • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, rheumatologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
  • AND the patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • Previously approved for the requested agent through the plan’s prior authorization process AND
  • Patient has had clinical benefit with the requested agent AND
  • ONE of the following regarding concomitant therapy:
  • • The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR
  • • The patient will be using the requested agent in combination with another immunomodulatory agent AND BOTH of the following are met:
  • – The prescribing information for the requested agent does NOT limit the use with another immunomodulatory agent AND
  • – There is support for the use of combination therapy (submitted copy of clinical trials, phase III studies, or guidelines required)
  • AND ONE of the following:
  • • The patient has a diagnosis of mild severity plaque psoriasis OR
  • • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, rheumatologist), or has consulted with one
  • AND the patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months