Skip to content
The Policy VaultThe Policy Vault

Ebglyss (lebrikizumab-lbkz) — Blue Cross Blue Shield of Montana

other FDA labeled indications for requested agent and route of administration

Initial criteria

  • Requested agent is eligible for continuation of therapy AND 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 new initiation criteria below apply.
  • Diagnosis of moderate-to-severe atopic dermatitis (AD) AND ONE of: ≥10% body surface area involvement OR involvement of difficult-to-treat sites (hands, feet, face, neck, scalp, genitals/groin, skin folds) OR EASI ≥16 OR IGA ≥3.
  • Inadequate response, intolerance, hypersensitivity, or FDA labeled contraindication to at least ONE medium-, high-, or super-potency topical corticosteroid AND inadequate response, intolerance, hypersensitivity, or FDA labeled contraindication to ONE topical calcineurin inhibitor (e.g., Elidel/pimecrolimus, Protopic/tacrolimus).
  • Alternatively, medication history indicates use of another biologic immunomodulator agent that is FDA-labeled or supported in compendia for AD.
  • Prescriber has documented baseline pruritus and other symptom severity.
  • Patient age is within FDA labeling for requested indication OR supported in compendia.
  • Patient currently treated with and will continue topical emollients and good skin care practices.
  • If requested agent is Adbry for AD, ONE of: patient age <18 years OR initiating therapy OR treated <16 consecutive weeks OR treated ≥16 weeks AND (if weight <100 kg AND achieved clear/almost clear skin → dose reduction to 300 mg q4w OR if not clear/almost clear skin OR support exists for q2w dosing; if weight ≥100 kg → continue criteria per labeling).
  • If requested agent is Ebglyss for AD, patient weighs ≥40 kg.
  • Prescriber is a dermatologist, allergist, immunologist, or has consulted with a specialist in the area of the patient’s diagnosis.
  • Patient will NOT use the requested agent concurrently with another immunomodulator (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR if using in combination, BOTH: product labeling does not limit use with another immunomodulator AND supportive evidence (clinical trial/guidelines) is submitted.
  • Patient does NOT have any FDA labeled contraindications to the requested agent.

Approval duration

12 months (BCBSIL, BCBSMT, BCBSTX); 6 months (all other plans)