Vtama — Blue Cross Blue Shield of Montana

Initial criteria

• ONE of the following: (A) Diagnosis of plaque psoriasis AND BOTH of the following: (1) Affected body surface area (BSA) ≤ 20% AND (2) ONE of the following: (A) Tried and had inadequate response to a topical corticosteroid or topical calcineurin inhibitor used in treatment of plaque psoriasis after ≥ 2-week duration OR (B) Intolerance or hypersensitivity to therapy with topical corticosteroids or topical calcineurin inhibitors used in treatment of plaque psoriasis OR (C) FDA labeled contraindication to ALL topical corticosteroids and ALL topical calcineurin inhibitors used in treatment of plaque psoriasis OR (B) Diagnosis of atopic dermatitis (AD) AND BOTH of the following: (1) ONE of the following: (A) Tried and had inadequate response to at least a low-potency topical corticosteroid or topical calcineurin inhibitor or topical emollients used in treatment of AD after ≥ 4-week duration OR (B) Intolerance or hypersensitivity to therapy with low-potency topical corticosteroid or topical calcineurin inhibitor used in treatment of AD OR (C) FDA labeled contraindication to ALL low-potency topical corticosteroid or topical calcineurin inhibitor used in treatment of AD AND (2) 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 requested agent OR (C) Patient has another FDA labeled indication for the requested agent and route of administration
• If the patient has an FDA labeled indication, ONE of the following: (A) Patient’s age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient’s age for the requested indication
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist) or has consulted with such a specialist
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Alternate approval path (for members residing in Ohio and plan is Fully Insured or HIM Shop (SG)): BOTH of the following: (A) Patient does NOT have any FDA labeled contraindications to the requested agent AND (B) ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use as generally safe and effective

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist) or has consulted with such a specialist
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL and BCSBTX); otherwise 3 months for atopic dermatitis, 12 months for plaque psoriasis and other indications