Xeljanz XR — Blue Cross Blue Shield of New Mexico

Initial criteria

• Has tried and had an inadequate response to TWO Step 1 agents for the requested indication after at least a 3-month duration of therapy per agent and an intolerance or hypersensitivity to ONE Step 1 agent for the requested indication OR
• Has tried and had an inadequate response to ONE Step 1 agent for the requested indication after at least a 3-month duration of therapy and an intolerance or hypersensitivity to TWO Step 1 agents for the requested indication OR
• Has an intolerance or hypersensitivity to THREE Step 1 agents for the requested indication OR
• The patient has an FDA labeled contraindication to ALL Step 1 agents for the requested indication OR
• ALL of the Step 1 agents are not clinically appropriate for the patient AND the prescriber has provided a complete list of previously tried agents for the requested indication OR
• The patient is currently being treated with the requested agent and is currently stable on the requested agent [chart notes required] OR
• The required prerequisite biologic immunomodulator agent(s) for the requested indication were discontinued due to lack of efficacy/effectiveness, diminished effect, or an adverse event [chart notes required] OR
• The required prerequisite biologic immunomodulator agent(s) for the requested indication are expected to be ineffective, cause adherence barriers, worsen comorbid conditions, or be medically inappropriate [chart notes required] OR
• The patient has tried another prescription drug in the same pharmacologic class or mechanism of action as the required prerequisite biologic immunomodulator for the indication, discontinued due to lack of efficacy/effectiveness or adverse event [chart notes required] AND
• If Omvoh is requested for Crohn's disease or ulcerative colitis: received or will receive Omvoh IV induction therapy AND
• If Entyvio is requested for Crohn's disease or ulcerative colitis: received or will receive at least 2 doses of Entyvio IV therapy AND
• If Skyrizi is requested for Crohn's disease or ulcerative colitis: received or will receive Skyrizi IV induction therapy AND
• If Zymfentra is requested for Crohn's disease or ulcerative colitis: received or will receive an infliximab IV product for induction therapy AND
• If Tremfya is requested for ulcerative colitis: received or will receive Tremfya IV for induction therapy AND
• If age-based: patient's age is within FDA labeling or supported by evidence for the indication AND
• If Cosentyx 300 mg is requested as maintenance dosing: ONE of the following: (A) moderate to severe plaque psoriasis ± psoriatic arthritis, 300 mg every 4 weeks OR (B) hidradenitis suppurativa, 300 mg every 4 weeks OR 300 mg every 2 weeks after inadequate response to 300 mg q4w for ≥3 months OR (C) active psoriatic arthritis or ankylosing spondylitis, 300 mg every 4 weeks after inadequate response to 150 mg q4w for ≥3 months AND
• If Tremfya 200 mg is requested: diagnosis of Crohn’s disease or ulcerative colitis AND
• If Omvoh 300 mg is requested as maintenance dosing: diagnosis of Crohn’s disease AND
• If Actemra is requested for systemic sclerosis associated interstitial lung disease: must be Actemra syringe (Actemra ACTpen not approvable) AND
• If Kevzara is requested for polyarticular juvenile idiopathic arthritis: patient weighs ≥63 kg AND
• If patient has moderate-to-severe atopic dermatitis: currently treated with topical emollients and practicing good skin care AND will continue these while on therapy AND
• Prescriber is a specialist (or has consulted a specialist) in the relevant disease area AND
• Patient will NOT be using the requested agent in combination with another immunomodulatory agent OR combination only allowed if prescribing info permits and supporting evidence is submitted AND
• Patient does NOT have any FDA labeled contraindications to the requested agent AND
• If prescribing info requires TB testing: patient tested for latent TB and if positive started therapy for TB OR prescribing info does not require TB testing AND
• For Ohio members (Fully Insured or HIM Shop): no FDA contraindication AND indication must be FDA labeled, compendia supported, or supported by at least two major peer-reviewed clinical trials

Reauthorization criteria

• Request is not for use of Olumiant or Actemra in COVID-19 hospitalized adults requiring oxygen or mechanical support AND
• Patient previously approved for requested agent through plan’s PA process AND
• If atopic dermatitis: had clinical benefit AND will continue maintenance therapies (topical emollients, good skin care) OR
• If polymyalgia rheumatica: had clinical benefit AND if Kevzara, patient does not have neutropenia (ANC <1000/mm3), thrombocytopenia (<100000/mm3), or AST/ALT elevations ≥3x ULN OR
• For all other diagnoses: patient has had clinical benefit with the requested agent AND
• Prescriber is a specialist (or has consulted specialist) for the diagnosis AND
• Patient will NOT use combination with another immunomodulatory agent unless prescribing info allows and supportive evidence is provided AND
• Requested agent is eligible for continuation of therapy

Approval duration

12 months (Rinvoq for AD 6 months; Siliq for PS 16 weeks; Xeljanz/XR for UC induction 16 weeks)