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Nemluvio (nemolizumab-ilto) — Blue Cross Blue Shield of New Mexico

Prurigo nodularis

Initial criteria

  • Requested quantity (dose) does NOT exceed the program quantity limit OR
  • Requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
  • A. Requested agent is Nemluvio for a diagnosis of prurigo nodularis AND ONE of the following:
  • 1. Patient weighs less than 90 kg AND BOTH of the following:
  • A. Request is for an initial loading dose AND
  • B. Requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication OR
  • 2. Patient weighs 90 kg or greater AND requested quantity (dose) does NOT exceed 60 mg every 4 weeks OR
  • B. BOTH of the following:
  • 1. Requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
  • 2. There is support for therapy with a higher dose for the requested indication OR
  • C. BOTH of the following:
  • 1. Requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
  • 2. There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit

Approval duration

initial 4 months, renewal 12 months (BCBSIL 12 months)