budesonide oral suspension 2 MG/10ML — Blue Cross Blue Shield of New Mexico

eosinophilic esophagitis (EoE)

Initial criteria

1. Diagnosis of eosinophilic esophagitis (EoE) confirmed by ALL of the following: (A) Chronic symptoms of esophageal dysfunction AND (B) ≥15 eosinophils per high-power field on esophageal biopsy AND (C) Other potential causes ruled out
2. ONE of the following: (A) Tried and had inadequate response to ONE standard corticosteroid therapy (swallowed budesonide nebulizer suspension or swallowed fluticasone from MDI) after ≥8 weeks OR (B) Intolerance or hypersensitivity to ONE standard corticosteroid therapy not expected with requested agent OR (C) FDA labeled contraindication to ALL standard corticosteroid therapies not expected with requested agent OR (D) Tried and had inadequate response to ONE proton pump inhibitor (PPI) after ≥8 weeks OR (E) Intolerance or hypersensitivity to ONE PPI OR (F) FDA labeled contraindication to ALL PPIs
3. ONE of the following: (A) Patient’s age within FDA labeling for the requested indication OR (B) Support exists for use in the patient’s age group for requested indication
4. Prescriber is a specialist in gastroenterology, allergy, or immunology, OR has consulted with one
5. Patient does NOT have any FDA labeled contraindications to the requested agent
6. ONE of the following: (A) Patient has NOT previously been treated with a 12-week course of the requested agent OR (B) Patient has previously been treated and there is support for an additional course

The patient has previously been treated with a course of therapy with the requested agent AND there is support for an additional course of therapy with the requested agent

BCBSIL, BCBSMT, BCBSTX:12 months; others:3 months