biologic immunomodulator agents — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Patient is currently treated and stable on the requested agent OR
• Has tried and had an inadequate response to ONE conventional agent (6-mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) after at least a 3-month duration OR
• Conventional agent discontinued due to lack of efficacy, diminished effect, or AE OR
• Intolerance or hypersensitivity to ONE conventional agent OR
• FDA labeled contraindication to ALL conventional agents OR
• Conventional agent expected to be ineffective or cause adherence barriers, worsen comorbidities, harm, or limit function OR
• Not in the best interest of the patient based on medical necessity OR
• Patient tried another drug in same class as conventional agent and discontinued due to inefficacy or AE OR
• Severely active UC OR
• Medication history indicates use of another biologic immunomodulator FDA labeled or supported for UC