Otezla (apremilast) — Blue Cross Blue Shield of Oklahoma

Initial criteria

• The patient tried and had inadequate response, intolerance, or contraindication to at least ONE conventional agent used in the treatment of Behçet disease (e.g., azathioprine) OR used another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of Behçet disease
• The patient’s medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of Behçet disease OR
• The patient has another FDA labeled indication for the requested agent and route of administration AND
• The patient’s age is within FDA labeling for the requested indication OR there is support for using the requested agent for the patient’s age for the requested indication OR the patient has another indication supported in compendia for the requested agent and route of administration
• ONE of the following regarding concomitant therapy: (A) The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) If used with another immunomodulatory agent, BOTH: (1) the prescribing information does NOT limit combination use AND (2) support for combination therapy is provided (clinical trials, phase III studies, or guidelines)
• ONE of the following: (A) The patient has a diagnosis of mild severity plaque psoriasis OR (B) The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, rheumatologist), or has consulted with a specialist
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s prior authorization process
• The patient has had clinical benefit with the requested agent
• The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR if used in combination, BOTH of the following: (1) prescribing information does NOT limit combination use AND (2) support for combination therapy is provided (clinical trials, phase III studies, or guidelines)
• ONE of the following: (A) The patient has a diagnosis of mild severity plaque psoriasis OR (B) The prescriber is a specialist or has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months