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Zeposia — Blue Cross Blue Shield of Kansas

Relapsing forms of multiple sclerosis

Preferred products

  • Adalimumab-aaty
  • Adalimumab-adaz
  • Hadlima
  • Simlandi
  • Selarsdi
  • Steqeyma
  • Yesintek

Initial criteria

  • The requested agent is eligible for continuation of therapy AND ONE of the following: • The patient has been treated with the requested agent within the past 90 days OR • The prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed
  • OR BOTH of the following: (for new starts)
  • For multiple sclerosis: • The patient has a relapsing form of MS AND • The patient will NOT be using the requested agent in combination with another disease modifying agent (DMA) used for the requested indication OR will use only in combination with Mavenclad (cladribine) with supportive evidence
  • For ulcerative colitis: • The patient has a diagnosis of moderately to severely active ulcerative colitis AND ALL of the following: – The patient has tried and had an inadequate response to ONE conventional agent (6-mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) for at least 3 months OR has severely active UC OR has intolerance/hypersensitivity/contraindication to conventional agents – The patient has tried and had an inadequate response to at least TWO Step 1 immunomodulatory agents OR intolerance/hypersensitivity/contraindication to them – The patient will NOT be using the requested agent in combination with an immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) unless permitted by prescribing information and supported by documentation
  • The patient’s age is within FDA labeling for the indication OR has supporting evidence for off-label age use
  • Electrocardiogram performed within 6 months prior to initiation
  • Prescriber is a neurologist (for MS) or gastroenterologist (for UC), or has consulted with a specialist
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • Compendia allowed: AHFS or DrugDex 1 or 2a evidence level

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s prior authorization process
  • The patient has had clinical benefit with the requested agent
  • The prescriber is a specialist (neurologist for MS, gastroenterologist for UC) or has consulted with a specialist
  • For multiple sclerosis: • The patient will NOT be using the requested agent in combination with another DMA for the requested indication OR only with Mavenclad (cladribine) with supportive evidence
  • For ulcerative colitis: • The patient will NOT be using the requested agent in combination with another immunomodulatory agent unless prescribing information permits and there is supportive evidence
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months