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Cosentyx 300 mg — Blue Cross Blue Shield of Oklahoma

Crohn's disease

Initial criteria

  • 1. Metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND the use of the requested agent is consistent with best practices or supported by peer-reviewed, evidence-based literature and FDA approval.
  • 2. For Step 1b agents: Patient has tried and had an inadequate response to ONE TNF inhibitor after ≥ 3 months OR has intolerance/hypersensitivity to ONE TNF inhibitor OR contraindication to ALL TNF inhibitors OR ALL TNF inhibitors not clinically appropriate with prescriber list of previously tried agents.
  • 3. For Step 2 agents: Patient has tried and had an inadequate response to ONE Step 1 agent after ≥ 3 months OR has intolerance/hypersensitivity to ONE Step 1 agent OR contraindication to ALL Step 1 agents OR ALL Step 1 agents not clinically appropriate with prescriber list of previously tried agents.
  • 4. For Step 3a agents: Patient has tried and had an inadequate response to TWO Step 1 agents after ≥ 3 months per agent OR combination of inadequate response/intolerance to Step 1 agents OR contraindication to ALL Step 1 agents OR ALL Step 1 agents not clinically appropriate with prescriber list of previously tried agents.
  • 5. For Step 3b agents: Patient has tried and had an inadequate response to TWO agents from Step 1 and/or Step 2 after ≥ 3 months per agent, or combinations of inadequate response/intolerance, contraindication to ALL Step 1 and 2 agents, or Step 1 and 2 not clinically appropriate with prescriber list of previously tried agents.
  • 6. For Step 3c agents: Patient has tried and had an inadequate response to THREE Step 1 agents (≥3 months per agent) or combinations of inadequate response/intolerance/hypersensitivity, contraindication to ALL Step 1 agents, or Step 1 not clinically appropriate with prescriber list of previously tried agents.
  • 7. Patient currently treated with and stable on requested agent [chart notes required].
  • 8. Prerequisite biologic agent discontinued due to lack of efficacy, diminished effect, or adverse event OR expected to be ineffective or clinically inappropriate or not in patient's best interest or another similar class drug failed due to same reasons.
  • 9. Cosentyx 300 mg requested as maintenance dosing: A. Plaque psoriasis with/without psoriatic arthritis and 300 mg q4w; OR B. Hidradenitis suppurativa with 300 mg q4w or q2w after inadequate response to q4w for ≥3 months; OR C. Active PsA or AS with 300 mg q4w after inadequate response to 150 mg q4w for ≥3 months.
  • 10. Tremfya 200 mg requested: diagnosis of Crohn’s disease or ulcerative colitis required.
  • 11. Omvoh 300 mg requested: diagnosis of Crohn’s disease required.
  • 12. Actemra for systemic sclerosis associated interstitial lung disease: must request Actemra syringe (not ACTpen).
  • 13. Patient does NOT have any FDA-labeled contraindications to requested agent.

Approval duration

12 months