Ebglyss — Blue Cross Blue Shield of Montana

moderate-to-severe atopic dermatitis

Initial criteria

Patient is under age 18 years AND does NOT have any FDA labeled contraindications to the requested agent AND has an indication supported in TWO major peer-reviewed journal articles as generally safe and effective AND there is support for an age in the patient's age bracket (infancy, childhood, adolescence) in TWO major peer-reviewed journal articles as generally safe and effective OR
Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient does NOT have any FDA labeled contraindications to the requested agent AND ONE of the following: patient has another FDA labeled indication for the requested agent and route OR indication is supported in compendia for the requested agent and route OR prescriber submitted TWO peer-reviewed journal articles supporting proposed use as generally safe and effective
Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (narrative supportive); Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (narrative supportive), DrugDex level 1, 2A, or 2B, Clinical Pharmacology (narrative supportive), LexiDrugs evidence level A, peer-reviewed medical literature

Patient previously approved for requested agent through prior authorization process AND
For moderate-to-severe atopic dermatitis: patient has reduction or stabilization from baseline of affected body surface area OR flares OR pruritus/erythema/edema/xerosis/erosions-excoriations/oozing-crusting/lichenification OR decrease in EASI score OR decrease in IGA score AND will continue standard maintenance therapies (topical emollients, good skin care) with requested agent OR
For diagnosis other than moderate-to-severe atopic dermatitis: patient has had clinical benefit with requested agent
If requested agent is Adbry for atopic dermatitis, then ONE of the following: patient age <18 years OR initiating therapy OR treated <16 consecutive weeks OR treated ≥16 consecutive weeks AND patient weighs <100 kg with clear/almost clear skin and dose reduced to 300 mg every 4 weeks OR patient has not achieved clear/almost clear skin OR support for 300 mg every 2 weeks OR patient weighs ≥100 kg (criteria continue as applicable)
Prescriber is a specialist (dermatologist, allergist, immunologist) or has consulted with such specialist
Patient will NOT use requested agent with another immunomodulatory agent (TNF inhibitor, JAK inhibitor, IL-4 inhibitor) OR if combination, both the prescribing information does NOT limit such combination AND documentation submitted supporting combination therapy
Patient does NOT have any FDA labeled contraindications to requested agent

12 months