Opzelura (ruxolitinib phosphate) — Blue Cross Blue Shield of Montana
other FDA labeled indication
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications to Opzelura
- ONE of the following: (A) Patient has another FDA labeled indication for Opzelura and route of administration OR (B) Patient has another indication supported in compendia for Opzelura and route of administration OR (C) Prescriber has submitted TWO peer‑reviewed journal articles supporting proposed use as generally safe and effective (randomized, double‑blind, placebo‑controlled acceptable)
- Non-oncology compendia: DrugDex level 1, 2A or 2B, AHFS‑DI supportive narrative; Oncology compendia: NCCN 1 or 2A, AHFS‑DI supportive narrative, DrugDex level 1, 2A, 2B, or Clinical Pharmacology supportive narrative, LexiDrugs evidence level A, or supportive peer‑reviewed literature
Approval duration
12 months