biologic immunomodulator agents — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Has tried and had inadequate response to TWO different NSAIDs after at least a 4-week total duration OR
• Has inadequate response to ONE NSAID after ≥4 weeks and intolerance/hypersensitivity to another OR
• Intolerance/hypersensitivity to TWO NSAIDs OR
• FDA labeled contraindication to ALL NSAIDs OR
• Medication history indicates use of another biologic immunomodulator labeled or supported for AS