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

Initial criteria

• Patient has diagnosis of nonsegmental vitiligo
• Body surface area (BSA) ≤ 10%
• ONE of the following:
• A. BOTH of the following: (1) Patient has stage four advanced metastatic cancer (or associated condition) and (2) Use is consistent with best practices, supported by peer‑reviewed evidence, and FDA approved for such use OR
• B. For vitiligo impacting areas OTHER THAN face, neck, axillary, or groin: (1) Tried and had inadequate response to at least a medium‑potency topical corticosteroid after ≥ 2‑week therapy OR (2) Has intolerance or hypersensitivity to at least a medium‑potency topical corticosteroid OR (3) Has FDA labeled contraindication to ALL medium‑, high‑, and super‑potency topical corticosteroids OR
• C. For vitiligo on face, neck, axillary, or groin: (1) Tried and had inadequate response to at least a medium‑potency topical corticosteroid after ≥ 2‑week therapy OR (2) Tried and had inadequate response to a topical calcineurin inhibitor used in vitiligo OR (3) Has intolerance or hypersensitivity to at least a medium‑potency topical corticosteroid OR a topical calcineurin inhibitor OR (4) Has FDA labeled contraindication to ALL medium‑, high‑, and super‑potency topical corticosteroids AND ALL topical calcineurin inhibitors
• 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, prescribing information does not limit such use and supportive evidence provided
• Patient has no FDA labeled contraindications to Opzelura

Approval duration

6 months