biologic immunomodulator agents — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Has tried and had an inadequate response to ONE oral or periocular/intravitreal corticosteroid injection after at least a 2-week duration OR intolerance/hypersensitivity OR contraindication to all corticosteroids AND
• Has tried and had an inadequate response to ONE conventional systemic agent (azathioprine, mycophenolate, methotrexate, cyclosporine, tacrolimus) after at least a 3-month duration OR intolerance/hypersensitivity OR contraindication to all conventional systemic agents OR patient has severe, active, sight-threatening disease OR medication history shows another biologic immunomodulator used for this indication