Omvoh 300 mg — Blue Cross Blue Shield of Montana

Initial criteria

• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., rheumatologist for JIA, PsA, RA; gastroenterologist for CD, UC; dermatologist for PS, AD; pulmonologist, radiologist, pathologist, rheumatologist for SSc-ILD; allergist, immunologist for AD) or has consulted with such a specialist
• ONE of the following: (A) The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) If combined use is planned, BOTH of the following: (1) labeling does not limit combination use AND (2) supporting evidence for combination therapy provided
• Patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of: (A) prescribing information requires testing for latent TB and patient has been tested and if positive begun therapy OR (B) the prescribing information does not require TB testing

Reauthorization criteria

• Request is NOT for use of Olumiant or Actemra for COVID-19 treatment
• If request is for alopecia areata, condition is not restricted from coverage
• Patient previously approved for the requested agent through prior authorization
• Depending on indication: (A) For moderate to severe atopic dermatitis: clinical benefit documented and continuation of maintenance care (e.g., topical emollients) OR (B) For polymyalgia rheumatica: clinical benefit documented and if Kevzara, no neutropenia (ANC < 1,000/mm3), thrombocytopenia (platelets < 100,000/mm3), or AST/ALT >3x ULN OR (C) For all other indications: clinical benefit documented
• Prescriber is or has consulted a specialist in the area of patient’s diagnosis
• ONE of the following regarding combination use: (A) Not used with another immunomodulatory agent OR (B) If combination use, BOTH: (1) labeling allows combination; (2) supporting evidence provided
• ONE of the following: (A) requested agent eligible for continuation (except Actemra) OR (B) follows step therapy logic per step table (Step 1a, 1b, 2, 3a, 3b, 3c) including: inadequate response, intolerance, hypersensitivity, or contraindication to required prior step agents for ≥3 months each
• If Cosentyx 300 mg requested as maintenance: appropriate diagnosis (PS, PsA, AS, HS) and meets dosing and prior response conditions
• If Tremfya 200 mg requested: diagnosis of Crohn’s disease or ulcerative colitis
• If Omvoh 300 mg requested for maintenance: diagnosis of Crohn’s disease
• If Actemra requested for SSc-ILD: syringe formulation requested (ACTpen not approvable)
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (except where noted: Rinvoq for AD 6 months; Siliq for PS 16 weeks; Xeljanz/Xeljanz XR for UC induction 16 weeks)