Opzelura (ruxolitinib phosphate) — Blue Cross Blue Shield of Montana

Initial criteria

• Patient has diagnosis of mild to moderate atopic dermatitis (AD)
• Body surface area (BSA) ≤ 20%
• Patient is NOT immunocompromised
• ONE of the following: (A) Tried and had inadequate response to at least a low-potency topical corticosteroid used in AD after ≥ 4-week therapy OR (B) Has intolerance or hypersensitivity to at least a low-potency topical corticosteroid used in AD OR (C) Has FDA labeled contraindication to ALL topical corticosteroids used in AD
• ONE of the following: (A) Tried and had inadequate response to a topical calcineurin inhibitor used in AD after ≥ 6-week therapy OR (B) Has intolerance or hypersensitivity to a topical calcineurin inhibitor used in AD OR (C) Has FDA labeled contraindication to ALL topical calcineurin inhibitors used in AD
• BOTH of the following: (A) Currently treated with topical emollients and practicing good skin care AND (B) Will continue use of topical emollients and good skin care practices in combination with Opzelura
• Prescriber is a specialist (e.g., dermatologist) or has consulted with a specialist
• ONE of the following: (A) Will NOT use in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL‑4 inhibitors) OR (B) If used in combination, the prescribing information does not limit such use and supporting documentation is provided
• Patient has no FDA labeled contraindications to Opzelura

Approval duration

3 months