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ozanimod — Blue Cross Blue Shield of Oklahoma

moderately to severely active ulcerative colitis

Preferred products

  • Omvoh
  • Selarsdi
  • Simponi
  • Steqeym
  • Skyrizi
  • Stelara
  • Tremfya
  • Velsipity
  • Humira
  • Hadlima
  • Adalimumab-aaty
  • Adalimumab-adaz
  • Simlandi
  • Xeljanz
  • Xeljanz XR

Initial criteria

  • ONE of the following: (A) The requested agent is eligible for continuation of therapy AND prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed OR (B) All of the following apply:
  • For multiple sclerosis: patient has a relapsing form of MS AND ONE of the following: (1) will NOT be using the requested agent in combination with another disease modifying agent for MS OR (2) will be used in combination with Mavenclad with support for use between Mavenclad cycles.
  • For ulcerative colitis: patient has moderately to severely active UC AND ALL of the following: (1) ONE of the following: (A) tried and had inadequate response to ONE conventional agent (6‑mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) for ≥3 months OR (B) has severely active UC OR (C) intolerance/hypersensitivity to ONE conventional agent OR (D) FDA labeled contraindication to ALL conventional agents OR (E) medication history indicates use of biologic immunomodulator for UC, AND (2) ONE of the following: (A) currently stable on the requested agent OR (B) tried and had inadequate response to at least TWO Step 1 immunomodulatory agents OR (C) TWO Step 1 agents discontinued due to lack of efficacy or adverse event OR (D) intolerance to at least TWO Step 1 agents OR (E) contraindication to ALL Step 1 agents OR (F) TWO Step 1 agents expected ineffective or harmful OR (G) TWO Step 1 agents not in best interest of patient OR (H) tried another agent in same class as TWO Step 1 agents that failed, AND (3) ONE of the following: (A) will NOT use in combination with another immunomodulatory (e.g. TNF inhibitors, JAK inhibitors, IL‑4 inhibitors) OR (B) combination supported and not limited by labeling with evidence required.
  • If patient has FDA approved indication: (1) age within FDA labeling OR supported by evidence; AND prescriber performed ECG within 6 months prior to initiation; AND prescriber is a specialist (neurologist for MS, gastroenterologist for UC) or has consulted one; AND patient has no FDA labeled contraindications.
  • Compendia Allowed: AHFS or DrugDex 1, 2a, or 2b evidence.

Approval duration

12 months