budesonide oral suspension 2 MG/10ML — Blue Cross Blue Shield of Montana

Initial criteria

• Diagnosis of eosinophilic esophagitis (EoE) confirmed by ALL of the following: chronic symptoms of esophageal dysfunction AND ≥15 eosinophils per high-power field on esophageal biopsy AND other causes ruled out
• Patient has ONE of the following: (A) tried and had inadequate response to ONE standard corticosteroid therapy (e.g., swallowed budesonide nebulizer suspension, swallowed fluticasone from MDI) used for EoE after ≥8 weeks OR (B) intolerance or hypersensitivity to ONE standard corticosteroid therapy not expected to occur with requested agent OR (C) FDA labeled contraindication to ALL standard corticosteroid therapies not expected to occur with requested agent OR (D) tried and had inadequate response to ONE PPI used for EoE after ≥8 weeks OR (E) intolerance or hypersensitivity to ONE PPI OR (F) FDA labeled contraindication to ALL PPIs
• If the patient has an FDA labeled indication, then ONE of the following: (A) patient age is within FDA labeling OR (B) support for use at patient’s age exists
• Prescriber is a specialist in gastroenterology, allergy, or immunology OR has consulted with a specialist
• Patient has no FDA labeled contraindications to requested agent
• ONE of the following applies: (A) patient has not previously been treated with a 12-week course of the requested agent OR (B) previously treated and there is support for an additional course

Approval duration

12 months (BCBSIL, BCBSMT, BCBSTX) or 3 months (all other plans)