belumosudil mesylate — Blue Cross Blue Shield of Montana

Initial criteria

• ONE of the following: A. The requested agent is eligible for continuation of therapy AND the following: - The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed OR B. BOTH of the following: - The patient has chronic graft-versus-host disease (chronic GVHD) AND - The patient has failed at least two prior lines of systemic therapy
• If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR B. There is support for using the requested agent for the patient’s age for the requested indication
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to therapy with the requested agent
• Alternate approval: - The member resides in Ohio AND - The plan is Fully Insured or HIM Shop (SG) AND BOTH of the following: A. The patient does NOT have any FDA labeled contraindications to the requested agent AND B. ONE of the following: 1. The patient has another FDA labeled indication for the requested agent and route of administration OR 2. The patient has another indication that is supported in compendia for the requested agent and route of administration OR 3. The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective (acceptable study designs include randomized, double blind, placebo-controlled clinical trials; case studies not acceptable)

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization Review process [patients not previously approved will require initial evaluation review]
• The patient has had clinical benefit with the requested agent
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months