Ebglyss — Blue Cross Blue Shield of Oklahoma

other indications supported in peer-reviewed journals or compendia

Initial criteria

The patient is under age < 18 years AND does not have any FDA labeled contraindications to the requested agent AND has an indication supported in TWO articles from major peer-reviewed professional medical journals (e.g., JAMA, NEJM, Lancet) as generally safe and effective AND there is support for the patient’s age bracket (infancy, childhood, adolescence) in TWO such articles OR
ALL of: member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient does NOT have any FDA labeled contraindications AND ONE of the following: (1) patient has another FDA labeled indication for the agent and route; OR (2) patient has another indication supported in compendia; OR (3) prescriber submitted TWO peer-reviewed journal articles supporting proposed use as safe and effective. Accepted compendia: DrugDex level 1, 2A, 2B; AHFS-DI narrative; NCCN 1 or 2A (if oncology); Clinical Pharmacology narrative; LexiDrugs level A.

Patient previously approved through plan’s Prior Authorization process AND ONE of: (A) Diagnosis of moderate-to-severe atopic dermatitis AND BOTH: (1) documented reduction or stabilization from baseline in affected body surface area, flares, pruritus/erythema/edema/xerosis/erosions/excoriations/oozing and crusting/lichenification, OR decrease in EASI or IGA score; AND (2) will continue standard maintenance therapies; OR (B) diagnosis other than moderate-to-severe atopic dermatitis AND has had clinical benefit with requested agent.
For Adbry requests for atopic dermatitis: ONE of: (A) patient age < 18 years OR (B) patient initiating therapy OR (C) patient treated < 16 consecutive weeks OR (D) patient treated ≥ 16 consecutive weeks AND ONE of: (1) patient weighs < 100 kg AND (a) achieved clear or almost clear skin and dose will be reduced to 300 mg every 4 weeks OR (b) not achieved clear or almost clear skin OR (c) supported for therapy using 300 mg every 2 weeks; OR (2) patient weighs ≥ 100 kg.
Prescriber is a specialist in the diagnosis area or has consulted one.
Requested agent not used concomitantly with another immunomodulatory agent (e.g., TNF, JAK, IL-4 inhibitors) OR if used concomitantly, prescribing info does not limit and there is supporting evidence for combination therapy.
Patient has no FDA labeled contraindications to the requested agent.

12 months