Otezla (apremilast) — Blue Cross Blue Shield of New Mexico

FDA labeled or compendia supported indications (e.g., Behçet’s Disease, plaque psoriasis, psoriatic arthritis)

Initial criteria

1. ONE of the following: A. Has inadequate response, intolerance, or contraindication to at least ONE conventional agent used for the indication (e.g., for Behçet’s Disease) B. Medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the indication
2. The patient’s age is within FDA labeling for the requested indication OR there is compendia support for use at patient’s age
3. The requested agent will NOT be used in combination with another immunomodulatory agent (TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR if used in combination BOTH of the following are met: a. The prescribing information does NOT limit concomitant use b. There is supporting evidence for combination therapy (submitted clinical trials, phase III studies, or guidelines)
4. ONE of the following: A. The patient has mild severity plaque psoriasis B. The prescriber is a specialist in the area of the diagnosis (e.g., dermatologist, rheumatologist) OR has consulted with a specialist
5. The patient does NOT have any FDA labeled contraindications to the requested agent

1. The patient has been previously approved for the requested agent through the plan’s prior authorization process
2. The patient has had clinical benefit with the requested agent
3. The patient will NOT be using the requested agent in combination with another immunomodulatory agent (TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR if used in combination BOTH of the following: a. The prescribing information does not limit concomitant use b. There is support for the use of combination therapy (submitted clinical trials, phase III studies, or guidelines required)
4. ONE of the following: A. The patient has a diagnosis of mild severity plaque psoriasis B. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, rheumatologist) or has consulted with a specialist
5. The patient does NOT have any FDA labeled contraindications to the requested agent

12 months