belumosudil mesylate — Blue Cross Blue Shield of New Mexico

chronic graft-versus-host disease (chronic GVHD)

Initial criteria

ONE of the following:
A. The requested agent is eligible for continuation of therapy AND the following: Agents Eligible for Continuation of Therapy: Rezurock — The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed
OR
B. BOTH of the following: 1. The patient has chronic graft-versus-host disease (chronic GVHD) AND 2. The patient has failed at least two prior lines of systemic therapy
AND
If the patient has an FDA labeled indication, then ONE of the following: A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR B. There is support for use for the patient’s age for the requested indication
AND
The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or has consulted with a specialist
AND
The patient does NOT have any FDA labeled contraindications to therapy with the requested agent

The patient has been previously approved for the requested agent through the plan’s Prior Authorization Review process
AND The patient has had clinical benefit with the requested agent
AND The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hematologist, oncologist) or has consulted with a specialist
AND The patient does NOT have any FDA labeled contraindications to the requested agent

12 months