Zeposia — Blue Cross Blue Shield of New Mexico

ulcerative colitis

Initial criteria

Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
Patient does NOT have any FDA labeled contraindications to the requested agent
ONE of the following: (a) patient has another FDA labeled indication for the agent and route of administration OR (b) patient has another indication supported in compendia (DrugDex level 1, 2A, or 2B; AHFS-DI supportive; NCCN 1 or 2A; Clinical Pharmacology supportive; LexiDrugs level A; peer-reviewed medical literature) OR (c) prescriber has submitted TWO peer-reviewed journal articles supporting the proposed use(s) as generally safe and effective

Patient previously approved for the requested agent through the plan’s Prior Authorization process
Patient has had clinical benefit with the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis or has consulted with such specialist
ONE of the following applies: For multiple sclerosis: (1) requested agent NOT used in combination with another disease modifying agent (DMA) OR (2) requested agent used in combination with Mavenclad (cladribine) AND there is support for use in combination (e.g., relapse between cycles of Mavenclad). For ulcerative colitis: (1) requested agent NOT used in combination with an immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (2) requested agent used in combination with another immunomodulatory agent AND (A) prescribing information does NOT limit such use AND (B) documentation supports combination therapy (clinical trials, phase III studies, or guideline evidence).
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months