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Vtama — Blue Cross Blue Shield of New Mexico

other FDA labeled indications

Initial criteria

  • ONE of the following:
  • A. Diagnosis of plaque psoriasis AND BOTH of the following:
  • 1. Affected body surface area (BSA) ≤ 20% AND
  • 2. ONE of the following:
  • A. Tried and had an inadequate response to a topical corticosteroid or topical calcineurin inhibitor used in plaque psoriasis after ≥ 2-week duration of therapy OR
  • B. Intolerance or hypersensitivity to topical corticosteroids or topical calcineurin inhibitors used in plaque psoriasis OR
  • C. FDA labeled contraindication to ALL topical corticosteroids and ALL topical calcineurin inhibitors used in plaque psoriasis
  • OR
  • B. Diagnosis of atopic dermatitis (AD) AND BOTH of the following:
  • 1. ONE of the following:
  • A. Tried and had an inadequate response to ≥ 4-week therapy with low-potency topical corticosteroid, topical calcineurin inhibitor, or topical emollients used in AD OR
  • B. Intolerance or hypersensitivity to low-potency topical corticosteroid or topical calcineurin inhibitor used in AD OR
  • C. FDA labeled contraindication to ALL low-potency topical corticosteroids or calcineurin inhibitors used in AD AND
  • 2. BOTH of the following:
  • A. Currently treated with topical emollients and practicing good skin care AND
  • B. Will continue topical emollients and good skin care practices in combination with requested agent
  • OR
  • C. Another FDA labeled indication for the requested agent and route of administration
  • AND, if the patient has an FDA labeled indication, ONE of the following:
  • A. Patient’s age is within FDA labeling for the requested indication and agent OR
  • B. There is support for using the requested agent for the patient’s age for the requested indication
  • AND prescriber is a specialist (e.g., dermatologist) or has consulted with one
  • AND patient has no FDA labeled contraindications to requested agent
  • Additional coverage option: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND BOTH of:
  • A. No FDA labeled contraindications to requested agent AND
  • B. ONE of:
  • 1. Another FDA labeled indication for requested agent and route of administration OR
  • 2. Indication supported in compendia for requested agent and route of administration OR
  • 3. Prescriber submits TWO articles from major peer-reviewed medical journals supporting proposed use as generally safe and effective (randomized, double blind, placebo controlled trials acceptable; case studies not acceptable)

Reauthorization criteria

  • Patient previously approved for the requested agent through plan’s prior authorization process
  • Patient has had clinical benefit with the requested agent
  • Prescriber is a specialist in area of diagnosis (e.g., dermatologist) or has consulted with a specialist
  • Patient does not have any FDA labeled contraindications to the requested agent

Approval duration

12 months (3 months for atopic dermatitis in non-BCBSIL/BCBSTX plans; 12 months for plaque psoriasis and all others)