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Cosentyx 300 mg — Blue Cross Blue Shield of Montana

ankylosing spondylitis

Initial criteria

  • All target agents except Actemra are eligible for continuation of therapy
  • Requested indication does not require any prerequisite biologic immunomodulator agents OR requested agent is a Step 1a agent
  • If requested agent is a Step 1b agent, patient has: inadequate response to one TNF inhibitor after ≥3 months OR intolerance/hypersensitivity to one TNF inhibitor OR FDA labeled contraindication to all TNF inhibitors OR all TNF inhibitors not clinically appropriate and prescriber provided list of prior agents
  • If requested agent is a Step 2 agent, patient has: inadequate response to one Step 1 agent after ≥3 months OR intolerance/hypersensitivity to one Step 1 agent OR FDA labeled contraindication to all Step 1 agents OR all Step 1 agents not clinically appropriate and prescriber provided list of prior agents
  • If requested agent is a Step 3a agent, patient has: inadequate response to two Step 1 agents after ≥3 months each OR inadequate response to one Step 1 and intolerance/hypersensitivity to one Step 1 OR intolerance/hypersensitivity to two Step 1 agents OR FDA labeled contraindication to all Step 1 agents OR all Step 1 agents not clinically appropriate and prescriber provided list of prior agents
  • If requested agent is a Step 3b agent, patient has: inadequate response to two agents from Step 1 and/or Step 2 after ≥3 months each OR inadequate response to one from Step 1 or Step 2 and intolerance/hypersensitivity to one from Step 1 or Step 2 OR intolerance/hypersensitivity to two from Step 1 and/or Step 2 OR FDA labeled contraindication to all Step 1 and 2 agents OR all Step 1 and 2 agents not clinically appropriate and prescriber provided list of prior agents
  • If requested agent is a Step 3c agent, patient has: inadequate response to three Step 1 agents after ≥3 months each OR inadequate response to two Step 1 agents and intolerance/hypersensitivity to one Step 1 OR inadequate response to one Step 1 and intolerance/hypersensitivity to two Step 1 OR intolerance/hypersensitivity to three Step 1 agents OR FDA labeled contraindication to all Step 1 agents OR all Step 1 agents not clinically appropriate and prescriber provided list of prior agents
  • Patient is currently stable on the requested agent
  • Required prerequisite biologic immunomodulator discontinued due to lack of efficacy, diminished effect, or adverse event OR expected to be ineffective OR cause adherence barrier OR worsen comorbidity OR decrease functional ability OR cause harm OR not in best interest based on medical necessity OR another drug in same class discontinued for lack of efficacy or adverse event (chart notes required)
  • Cosentyx 300 mg: for moderate to severe plaque psoriasis ± psoriatic arthritis, dose 300 mg every 4 weeks; OR for hidradenitis suppurativa, dose 300 mg every 4 weeks OR 300 mg every 2 weeks after inadequate response to 300 mg every 4 weeks after ≥3 months; OR for psoriatic arthritis or ankylosing spondylitis, dose 300 mg every 4 weeks after inadequate response to 150 mg every 4 weeks after ≥3 months
  • Tremfya 200 mg: patient has diagnosis of Crohn’s disease or ulcerative colitis
  • Omvoh 300 mg (maintenance): patient has diagnosis of Crohn’s disease
  • Actemra for systemic sclerosis associated interstitial lung disease: request must be for Actemra syringe (Actemra ACTpen not approvable)
  • Patient has no FDA labeled contraindications to the requested agent

Approval duration

12 months