Otezla XR — Blue Cross Blue Shield of New Mexico

Initial criteria

• Continuation of therapy: prescriber states patient has been treated with requested agent (not samples) within past 90 days AND is at risk if therapy is changed
• For psoriatic arthritis (PsA): ONE of the following: (1) Patient has stage four advanced, metastatic cancer and requested agent used for cancer or associated condition OR (2) Patient has tried and had an inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after ≥3 months OR (3) Has intolerance/hypersensitivity to ONE conventional agent OR (4) Has FDA-labeled contraindication to ALL conventional agents OR (5) Medication history shows use of another biologic immunomodulator labeled/supported for PsA
• For plaque psoriasis (PS): BOTH of the following: (1) ONE of: (A) Adult with mild to severe plaque psoriasis OR (B) Pediatric age ≥6 years with moderate to severe plaque psoriasis AND weight ≥20 kg AND (2) ONE of: (A) Patient has stage four advanced, metastatic cancer and requested agent used for cancer or associated condition OR (B) Tried and had inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA[phototherapy], tacrolimus, tazarotene, topical corticosteroids) after ≥3 months OR (C) Has intolerance/hypersensitivity to ONE conventional agent OR (D) Has FDA-labeled contraindication to ALL conventional agents OR (E) Medication history indicates use of another biologic immunomodulator labeled/supported for PS
• For Behçet’s disease (BD): ALL of the following: (1) Active oral ulcers associated with BD AND (2) ≥3 occurrences of oral ulcers in last 12 months AND (3) ONE of: (A) Patient has stage four advanced, metastatic cancer and requested agent used for cancer or associated condition OR (B) Tried and had inadequate response to ONE conventional agent (topical oral corticosteroids [triamcinolone dental paste], colchicine, etc.)