Omvoh — Blue Cross Blue Shield of Montana

Initial criteria

• Patient has failed or has FDA labeled contraindication to required Step 1 agents for the requested indication OR Step 1 agents are not clinically appropriate and prescriber has provided list of previously tried agents
• OR patient is currently being treated and stable on requested agent
• OR required prerequisite biologic immunomodulator(s) discontinued due to lack of efficacy, diminished effect, or adverse event
• OR prerequisite biologic immunomodulator(s) expected to be ineffective or harmful or not in best interest based on medical necessity
• OR patient has tried another drug in same pharmacologic class as prerequisite and discontinued due to lack of efficacy or adverse event [chart notes required]
• If Omvoh for Crohn’s/UC: patient has received Omvoh IV induction OR will receive Omvoh IV induction
• If Entyvio for Crohn’s/UC: patient has received ≥2 doses of Entyvio IV therapy OR will receive ≥2 doses of Entyvio IV therapy
• If Skyrizi for Crohn’s/UC: patient has received Skyrizi IV induction OR will receive Skyrizi IV induction
• If Zymfentra for Crohn’s/UC: patient has received infliximab IV induction OR will receive infliximab IV induction
• If Tremfya for ulcerative colitis: patient has received Tremfya IV induction OR will receive Tremfya IV induction
• Patient's age within FDA labeling OR use supported for patient’s age
• If Cosentyx 300 mg maintenance: moderate–severe plaque psoriasis with or without psoriatic arthritis, dose 300 mg q4wk OR hidradenitis suppurativa with 300 mg q4wk or q2wk after failure of q4wk ×3mo OR active psoriatic arthritis or ankylosing spondylitis with 300 mg q4wk after failure of 150 mg q4wk ×3mo
• If Tremfya 200 mg requested: patient has Crohn’s disease or ulcerative colitis
• If Omvoh 300 mg maintenance: patient has Crohn’s disease
• If Actemra for systemic sclerosis-associated ILD: must request Actemra syringe (ACTpen not approvable)
• If Kevzara for polyarticular juvenile idiopathic arthritis: patient weight ≥63 kg
• If moderate–severe atopic dermatitis: patient currently using topical emollients and practicing good skin care AND will continue emollients and good skin care concurrently
• Prescriber is or has consulted specialist appropriate for diagnosis
• Patient will not use combination immunomodulator therapy OR combination allowed per prescribing information and supported by clinical evidence
• Patient does not have FDA labeled contraindications
• If prescribing info requires TB testing: patient tested and if positive, started latent TB therapy; otherwise, if not required, criterion met

Reauthorization criteria

• Use not for COVID‑19 hospitalized adult treatment (Olumiant, Actemra excluded)
• Patient previously approved through plan PA process
• If moderate‑severe atopic dermatitis: clinical benefit shown AND will continue topical maintenance therapies
• If polymyalgia rheumatica: clinical benefit AND if Kevzara, no neutropenia (ANC<1000/mm³), no thrombocytopenia (platelets<100000/mm³), no AST/ALT>3×ULN
• Otherwise: clinical benefit with requested agent
• Prescriber is or has consulted appropriate specialist
• Patient not using with another immunomodulatory agent unless prescribing info allows and supported evidence provided
• Requested agent eligible for continuation of therapy (all except Actemra) OR indication does not require prerequisite agent OR requested agent is Step 1a for indication OR patient meets advanced metastatic cancer exemption

Approval duration

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