biologic immunomodulator agents — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Has tried and had an inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) used in the treatment of PsA after at least a 3-month duration of therapy OR has an intolerance/hypersensitivity to ONE conventional agent used in the treatment of PsA
• The patient has an FDA labeled contraindication to ALL conventional agents used in the treatment of PsA OR
• The patient has severe active PsA (e.g., erosive disease, elevated markers of inflammation attributable to PsA, long-term damage that interferes with function, rapidly progressive) OR
• The patient has concomitant severe psoriasis (e.g., >10% body surface area involvement, select locations, intractable pruritus, serious emotional consequences) OR
• The patient’s medication history indicates use of another biologic immunomodulator agent or Otezla that is FDA labeled or supported in compendia for PsA