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Zeposia (ozanimod) — Blue Cross Blue Shield of New Mexico

Moderately to severely active ulcerative colitis

Preferred products

  • Adalimumab-aaty
  • Adalimumab-adaz
  • Hadlima
  • Humira
  • Simlandi
  • Omvoh
  • Selarsdi
  • Simponi
  • Steqeym
  • Skyrizi
  • Stelara
  • Tremfya
  • Velsipity
  • Xeljanz
  • Xeljanz XR

Initial criteria

  • Continuation of therapy: Prescriber states patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed
  • Relapsing multiple sclerosis: Patient has a relapsing form of MS AND will NOT be using the requested agent in combination with another disease-modifying agent (DMA) OR will use in combination with Mavenclad (cladribine) with support for combination use (e.g., relapse between cycles of Mavenclad)
  • Ulcerative colitis: Patient has moderately to severely active UC AND ALL of the following:
  • • ONE of: Tried and had inadequate response to ONE conventional agent (6-mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) for at least 3 months OR Severely active UC OR Intolerance/hypersensitivity to ONE conventional agent OR FDA labeled contraindication to ALL conventional agents OR Use of another biologic immunomodulator agent that is FDA labeled or compendia-supported for UC
  • • ONE of: Currently treated and stable on requested agent OR Tried and inadequate response to at least TWO Step 1 immunomodulatory agents (see Step table) OR TWO Step 1 agents discontinued due to lack of efficacy, diminished effect, or adverse event OR Intolerance/hypersensitivity to at least TWO Step 1 agents OR FDA labeled contraindication to ALL Step 1 agents OR TWO Step 1 agents expected to be ineffective or not in patient’s best interest (medical necessity) OR Tried another drug in same class/mechanism as TWO Step 1 agents that was discontinued due to lack of efficacy or adverse event
  • • ONE of: Will NOT use requested agent in combination with other immunomodulators (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR combination supported with evidence and no labeling restriction
  • If patient has FDA-approved indication: age within FDA labeling OR supported for patient’s age
  • Electrocardiogram within 6 months prior to initiating treatment
  • Prescriber is specialist in diagnosis area or has consulted with appropriate specialist
  • Patient does NOT have any FDA-labeled contraindications
  • Compendia Allowed: AHFS or DrugDex level 1, 2a, or 2b evidence

Approval duration

12 months