biologic immunomodulators (target agents per policy) — Blue Cross Blue Shield of Oklahoma

Initial criteria

• The request is NOT for use of Olumiant or Actemra in the treatment of COVID-19 in hospitalized adults
• ONE of the following:
• A. The requested agent is eligible for continuation of therapy AND prescriber confirms patient has been treated with the requested agent (not samples) within past 90 days AND is at risk if therapy is changed OR
• B. The patient has an FDA labeled indication or compendia-supported indication for the requested agent and route of administration AND condition-specific criteria apply, e.g., rheumatoid arthritis with prior conventional therapy trial or contraindication

Approval duration

12 months