Xeljanz XR — Blue Cross Blue Shield of Kansas

Initial criteria

• Patient has tried and had an inadequate response to THREE Step 1 agents for the requested indication after at least 3 months per agent OR has tried TWO Step 1 with one intolerance/hypersensitivity OR ONE Step 1 with two intolerances OR intolerance/hypersensitivity to THREE Step 1 agents
• OR patient has FDA labeled contraindication to ALL Step 1 agents OR ALL Step 1 agents not clinically appropriate AND prescriber provided complete list of previously tried agents
• If Omvoh is requested for Crohn's disease or ulcerative colitis: patient has received Omvoh IV induction therapy OR will receive Omvoh IV for induction
• If Entyvio is requested for Crohn's disease or ulcerative colitis: patient has received at least 2 doses of Entyvio IV therapy OR will receive at least 2 doses
• If Skyrizi is requested for Crohn's disease or ulcerative colitis: patient has received Skyrizi IV induction OR will receive Skyrizi IV induction
• If Zymfentra is requested for Crohn's disease or ulcerative colitis: patient has received infliximab IV induction OR will receive infliximab IV induction
• If Tremfya is requested for ulcerative colitis: patient has received Tremfya IV induction OR will receive Tremfya IV induction
• Patient’s age is within or supported by FDA labeling for the requested indication
• If Cosentyx 300 mg requested maintenance: moderate to severe plaque psoriasis ± psoriatic arthritis (dose 300 mg q4w); OR hidradenitis suppurativa (dose 300 mg q4w OR 300 mg q2w after inadequate response to 300 mg q4w 3 months); OR active psoriatic arthritis/ankylosing spondylitis (dose 300 mg q4w after inadequate response to 150 mg q4w 3 months)
• If Tremfya 200 mg requested: diagnosis of Crohn's disease or ulcerative colitis
• If Omvoh 300 mg requested maintenance: diagnosis of Crohn’s disease
• If Actemra requested for systemic sclerosis associated interstitial lung disease: request must be Actemra syringe (ACTpen not approvable)
• If Kevzara requested for polyarticular juvenile idiopathic arthritis: patient weight ≥63 kg
• For atopic dermatitis: patient using topical emollients and good skin care and will continue such practices
• Prescriber is or has consulted with appropriate specialist
• Patient will NOT use requested agent with another immunomodulatory agent OR if used in combination, prescribing info allows and supporting evidence provided
• Patient has no FDA labeled contraindications to requested agent
• Testing and management for latent tuberculosis per prescribing information

Reauthorization criteria

• Request not for Actemra or Olumiant use in COVID-19 hospitalization
• If alopecia areata requested, indication must be covered under benefit
• Patient previously approved for requested agent
• For atopic dermatitis: clinical benefit and will continue topical care
• For polymyalgia rheumatica: clinical benefit and if Kevzara, no neutropenia (ANC <1000/mm^3), no thrombocytopenia (<100,000/mm^3), and no AST/ALT >3× ULN
• For other indications: patient has clinical benefit
• Prescriber is or has consulted with appropriate specialist
• Requested agent not used with another immunomodulatory agent OR if in combination, prescribing info allows and evidence supports use
• Requested agent eligible for continuation of therapy except Actemra, OR satisfies step requirements for Step 1a/1b/2/3 levels per step table (adequate trials, intolerance, contraindication, or clinical inappropriateness of required step agents)

Approval duration

12 months (except Rinvoq for AD 6 months; Siliq 16 weeks; Xeljanz/Xeljanz XR UC induction 16 weeks)