Eohilia — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 1. Diagnosis of eosinophilic esophagitis (EoE) confirmed by ALL of the following: A. Chronic symptoms of esophageal dysfunction AND B. ≥ 15 eosinophils per high-power field on esophageal biopsy AND C. Other causes of symptoms and esophageal eosinophilia ruled out AND
• 2. ONE of the following: A. Tried and had inadequate response to ≥ 1 standard corticosteroid therapy (e.g., swallowed budesonide nebulizer suspension, swallowed fluticasone from MDI) for at least 8 weeks OR B. Intolerance or hypersensitivity to ≥ 1 standard corticosteroid therapy not expected to occur with requested agent OR C. FDA labeled contraindication to ALL standard corticosteroid therapies not expected to occur with requested agent OR D. Tried and had inadequate response to ≥ 1 proton pump inhibitor (PPI) for at least 8 weeks OR E. Intolerance or hypersensitivity to ≥ 1 PPI OR F. FDA labeled contraindication to ALL PPIs
• 3. If patient has an FDA labeled indication, ONE of the following: A. Age within FDA labeling for requested indication OR B. Support for use in patient's age group for requested indication
• 4. Prescriber is a specialist in the area of diagnosis (e.g., gastroenterologist, allergist, immunologist) or has consulted with a specialist
• 5. Patient does NOT have any FDA labeled contraindications to the requested agent
• 6. ONE of the following: A. Patient has NOT previously been treated with a 12-week course of therapy with the requested agent OR B. Patient has previously been treated with a course of therapy with the requested agent and there is support for an additional course

Reauthorization criteria

• Patient previously treated with requested agent and there is support for an additional course of therapy

Approval duration

12 months (BCBSIL, BCBSMT, BCBSTX); 3 months (all other plans)