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Otezla/otezla xr 28 day t — Blue Cross Blue Shield of Oklahoma

Behcet’s disease (BD)

Initial criteria

  • ONE of the following:
  • A. Continuation of therapy: prescriber states the patient has been treated with the requested agent (not from samples) within the past 90 days AND is at risk if therapy is changed OR
  • B. BOTH of the following: (disease-specific criteria below)
  • For Psoriatic Arthritis (PsA):
  • – Patient has diagnosis of active PsA AND ONE of the following:
  • 1. Has tried and had inadequate response to ONE conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after at least 3 months OR
  • 2. Has intolerance or hypersensitivity to ONE conventional agent used for PsA OR
  • 3. Has FDA-labeled contraindication to ALL conventional agents for PsA OR
  • 4. Medication history indicates use of another biologic immunomodulator agent FDA labeled or supported in compendia for PsA.
  • For Plaque Psoriasis (PS):
  • – Patient has diagnosis of plaque psoriasis AND BOTH of the following:
  • 1. Either:
  • A. Adult with mild to severe plaque psoriasis OR
  • B. Pediatric patient age ≥ 6 years, with moderate to severe plaque psoriasis AND weight ≥ 20 kg.
  • 2. ONE of the following:
  • A. Has tried and had inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA, tacrolimus, tazarotene, topical corticosteroids) after at least 3 months OR
  • B. Has intolerance or hypersensitivity to ONE conventional agent for PS OR
  • C. Has FDA-labeled contraindication to ALL conventional agents for PS OR
  • D. Medication history indicates use of another biologic immunomodulator agent FDA labeled or supported in compendia for PS.
  • For Behcet’s disease (BD):
  • – Patient has diagnosis of BD AND ALL of the following:
  • 1. Active oral ulcers associated with BD AND
  • 2. ≥ 3 occurrences of oral ulcers in the last 12 months AND
  • 3. ONE of the following:
  • A. Has tried and had inadequate response to ONE conventional agent (topical oral corticosteroids [e.g., triamcinolone dental paste], colchicine) OR
  • B. Has intolerance or hypersensitivity to ONE conventional agent used for BD OR
  • C. Has FDA-labeled contraindication to ALL conventional agents for BD OR
  • D. Medication history indicates use of another biologic immunomodulator agent FDA labeled or supported in compendia for BD.