Ebglyss — Blue Cross Blue Shield of Oklahoma

Initial criteria

• ONE of the following: (A) The requested agent is eligible for continuation of therapy AND prescriber states patient has been treated with requested agent (starting on samples not approvable) within past 90 days AND is at risk if therapy is changed OR (B) BOTH of the following: (1) ONE of the following: (A) Patient has diagnosis of moderate-to-severe atopic dermatitis AND ALL of: ONE of the following: (A) at least 10% body surface area involvement OR (B) involvement of body sites difficult to treat with prolonged topical corticosteroid therapy (e.g., hands, feet, face, neck, scalp, genitals/groin, skin folds) OR (C) Eczema Area and Severity Index (EASI) score ≥ 16 OR (D) Investigator Global Assessment (IGA) score ≥ 3; AND ONE of the following: (A) BOTH of: (1) ONE of: (A) has tried and had inadequate response to ≥1 medium-potency topical corticosteroid used in AD after ≥4-week duration OR (B) has intolerance/hypersensitivity to ≥1 medium-potency topical corticosteroid OR (C) has FDA labeled contraindication to ALL medium-, high-, and super-potency topical corticosteroids; AND (2) ONE of: (A) has tried and had inadequate response to ≥1 topical calcineurin inhibitor (e.g., Elidel, Protopic) after ≥6-week duration OR (B) has intolerance or hypersensitivity to ≥1 topical calcineurin inhibitor OR (C) has FDA labeled contraindication to ALL topical calcineurin inhibitors) OR (B) patient’s medication history indicates use of another biologic immunomodulator agent FDA labeled or compendia supported for AD; AND prescriber has documented patient’s baseline pruritus and other symptom severity (erythema, edema, xerosis, erosions/excoriations, oozing/crusting, lichenification)
• Patient age within FDA labeling for requested indication OR support for use at that age OR compendia-supported indication
• If diagnosis is moderate-to-severe AD, BOTH: (A) patient currently treated with topical emollients and practicing good skin care AND (B) will continue topical emollients and good skin care with requested agent
• If requested agent is Adbry for AD, ONE of: (A) patient age < 18 years OR (B) initiating therapy OR (C) treated <16 consecutive weeks OR (D) treated ≥16 consecutive weeks AND (1) if weight <100 kg, then ONE of: (A) achieved clear/almost clear skin and dose reduced to 300 mg q4w OR (B) not achieved clear/almost clear skin OR (C) support for therapy at 300 mg q2w OR (2) if weight ≥100 kg)
• If requested agent is Ebglyss for AD, patient weight ≥40 kg
• Prescriber is specialist in diagnosis area (dermatologist, allergist, immunologist) OR has consulted with such specialist
• ONE of: (A) patient will NOT use requested agent with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) if used in combination, BOTH: (1) prescribing info does NOT limit such use AND (2) support for combination provided (clinical trials or guidelines)
• Patient does NOT have any FDA labeled contraindications to requested agent

Approval duration

6 months (BCBSOK)