Cibinqo — Blue Cross Blue Shield of Montana

Initial criteria

• Request is for a target agent eligible for continuation of therapy OR clinical criteria below are met
• Patient has a diagnosis of moderate-to-severe atopic dermatitis (AD) AND BOTH of the following:
• • ONE of the following: (a) at least 10% body surface area involvement OR (b) involvement of body sites difficult to treat with prolonged topical corticosteroid therapy (e.g., hands, feet, face, neck, scalp, genitals/groin, skin folds) OR (c) Eczema Area and Severity Index (EASI) ≥ 16 OR (d) Investigator Global Assessment (IGA) ≥ 3
• • ONE of the following: (a) inadequate response after ≥ 4 weeks, intolerance, or contraindication to at least one medium-potency topical corticosteroid AND (b) inadequate response after ≥ 6 weeks, intolerance, or contraindication to at least one topical calcineurin inhibitor (e.g., Elidel/pimecrolimus, Protopic/tacrolimus)
• OR patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for AD
• Patient has another FDA labeled indication or compendia-supported indication for the requested agent and age is within FDA labeling or supported in compendia
• If diagnosis is AD, BOTH of the following: patient is currently treated with topical emollients and good skin care AND will continue use of topical emollients and good skin care in combination with requested agent
• Patient has been tested for latent tuberculosis and if positive has begun therapy for latent TB
• Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted with a specialist
• Requested agent will NOT be used in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL‑4 inhibitors) OR combination use is supported and not limited by prescribing information
• Patient has no FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through plan's PA process
• Patient has had clinical benefit with the requested agent
• If diagnosis is moderate-to-severe AD, patient will continue standard maintenance therapies (topical emollients, good skin care) with the requested agent
• Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted with a specialist
• Requested agent not used concomitantly with another immunomodulatory agent unless supported and not limited by prescribing information
• Patient has no FDA labeled contraindications to the requested agent

Approval duration

12 months