Skip to content
The Policy VaultThe Policy Vault

Zeposia — Blue Cross Blue Shield of Montana

multiple sclerosis

Initial criteria

  • Member resides in Ohio
  • Plan is Fully Insured or HIM Shop (SG)
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • ONE of the following: patient has another FDA labeled indication for the requested agent and route of administration; patient has another indication supported in compendia for the requested agent and route of administration; OR prescriber has submitted TWO articles from major peer-reviewed medical journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use as safe and effective (case studies not acceptable)
  • Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (supportive narrative)
  • Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (supportive narrative), DrugDex level 1, 2A, or 2B, Clinical Pharmacology (supportive narrative), LexiDrugs evidence level A, or peer-reviewed medical literature

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., neurologist for multiple sclerosis, gastroenterologist for ulcerative colitis) OR has consulted with a specialist in the diagnosis area
  • For multiple sclerosis: ONE of the following: (1) patient will NOT be using the agent in combination with another disease modifying agent (DMA); OR (2) the agent will be used in combination with Mavenclad (cladribine) and there is support for combination use (e.g., relapse between cycles of Mavenclad)
  • For ulcerative colitis: ONE of the following: (1) patient will NOT be using the requested agent in combination with an immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors); OR (2) the agent will be used in combination with another immunomodulatory agent AND the prescribing information does NOT limit use with an immunomodulatory agent AND there is support for the combination (e.g., clinical trial, phase III study, or guideline evidence)
  • Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months