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The Policy VaultThe Policy Vault

Wezlana (ustekinumab-auub) — Blue Cross Blue Shield of Kansas

ulcerative colitis (UC)

Preferred products

  • Ustekinumab
  • Ustekinumab-aekn
  • Stelara (ustekinumab)
  • Selarsdi (ustekinumab-aekn)

Initial criteria

  • Requested agent is eligible for continuation of therapy OR meets the following.
  • Patient has an FDA labeled indication or indication supported in compendia for the requested agent and route of administration.
  • If psoriatic arthritis (PsA): has tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) for at least 3 months OR has intolerance/hypersensitivity to ONE conventional agent used for PsA OR has an FDA labeled contraindication to ALL conventional agents OR has severe active PsA (erosive, elevated ESR/CRP, long‑term damage, or rapidly progressive) OR has concomitant severe psoriasis OR medication history indicates use of another biologic immunomodulator or Otezla.
  • If plaque psoriasis (PS): has tried and had inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar, cyclosporine, methotrexate, pimecrolimus, PUVA, tacrolimus, tazarotene, topical corticosteroids) for at least 3 months OR has intolerance/hypersensitivity to ONE conventional agent OR FDA labeled contraindication to ALL conventional agents OR has severe active PS (≥10% BSA, select locations, intractable pruritus, serious emotional consequences) OR has concomitant severe PsA OR medication history indicates use of another biologic immunomodulator or Otezla.
  • If Crohn’s disease (CD): has tried and had inadequate response to ONE conventional agent (6‑mercaptopurine, azathioprine, corticosteroids—prednisone or budesonide EC capsule—, methotrexate) for at least 3 months OR intolerance/hypersensitivity to ONE conventional agent OR FDA labeled contraindication to ALL such agents OR medication history indicates use of another biologic immunomodulator.
  • If ulcerative colitis (UC): has tried and had inadequate response to ONE conventional agent (6‑mercaptopurine, azathioprine, balsalazide, corticosteroids) for at least 3 months OR intolerance/hypersensitivity to ONE conventional agent OR FDA labeled contraindication to ALL such agents.

Reauthorization criteria

  • Patient previously approved for requested agent through plan’s Prior Authorization process.
  • Patient has had clinical benefit with the requested agent.
  • Requested agent is preferred OR patient meets criteria of inadequate response/intolerance/hypersensitivity to preferred products as specified for initial evaluation.
  • Prescriber is a specialist in the area of diagnosis or has consulted one.
  • Patient will not use requested agent with another immunomodulator unless labeling allows and supporting data for combination are provided.
  • Patient does not have any FDA labeled contraindications to the requested agent.

Approval duration

12 months (UC: 12 weeks)