Rinvoq — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Has tried and had an inadequate response to TWO Step 1 agents for the requested indication after at least a 3‑month duration per agent and an intolerance or hypersensitivity to ONE Step 1 agent OR
• Has tried and had an inadequate response to ONE Step 1 agent after at least a 3‑month duration and an intolerance or hypersensitivity to TWO Step 1 agents OR
• Has intolerance or hypersensitivity to THREE Step 1 agents OR
• Has an FDA labeled contraindication to ALL Step 1 agents OR
• ALL Step 1 agents are not clinically appropriate AND prescriber has provided list of tried agents OR
• Patient is currently being treated and stable on the requested agent OR
• Required prerequisite biologic agent(s) discontinued due to lack of efficacy, diminished effect, or adverse event OR expected to be ineffective or not in best interest of patient OR not tolerated OR cause barriers or comorbid worsening OR decrease function OR cause harm OR
• Patient has tried another prescription drug in same pharmacologic class or mechanism as prerequisite agent and discontinued due to lack of efficacy, diminished effect, or adverse event AND
• If Omvoh for Crohn’s disease or ulcerative colitis, patient has received Omvoh IV for induction therapy OR will receive Omvoh IV for induction therapy if new to therapy AND
• If Entyvio for Crohn’s disease or ulcerative colitis, patient has received at least 2 doses of Entyvio IV therapy OR will receive at least 2 doses if new to therapy AND
• If Skyrizi for Crohn’s disease or ulcerative colitis, patient has received Skyrizi IV for induction therapy OR will receive Skyrizi IV if new to therapy AND
• If Zymfentra for Crohn’s disease or ulcerative colitis, patient has received an infliximab IV product for induction therapy OR will receive an infliximab IV product if new to therapy AND
• If Tremfya for ulcerative colitis, patient has received Tremfya IV for induction therapy OR will receive Tremfya IV if new to therapy AND
• If patient has an FDA labeled indication, patient’s age is within FDA labeling OR support exists for use at that age AND
• If Cosentyx 300 mg requested as maintenance dosing: moderate to severe plaque psoriasis ± psoriatic arthritis with 300 mg every 4 weeks OR hidradenitis suppurativa with 300 mg every 4 weeks or 300 mg every 2 weeks after ≥3‑month inadequate response to 4‑week dosing OR active psoriatic arthritis/ankylosing spondylitis with inadequate response to Cosentyx 150 mg every 4 weeks for ≥3 months AND
• If Tremfya 200 mg requested, patient has Crohn’s disease or ulcerative colitis AND
• If Omvoh 300 mg maintenance, patient has Crohn’s disease AND
• If Actemra for systemic sclerosis associated interstitial lung disease, request must be for Actemra syringe (ACTPen not approvable) AND
• If Kevzara for polyarticular JIA, patient weight ≥63 kg AND
• If moderate‑to‑severe atopic dermatitis, patient is currently treated with topical emollients and practicing good skin care AND will continue topical emollients and good skin care practices AND
• Prescriber is or consulted with a specialist appropriate to diagnosis AND
• Patient will not use requested agent concomitantly with another immunomodulator OR if combination used, prescribing information does not limit use and support for combination is submitted AND
• Patient does not have FDA labeled contraindications to requested agent AND
• If prescribing information requires TB testing, patient tested and treated if positive OR drug does not require testing

Reauthorization criteria

• Request is not for use of Olumiant or Actemra for COVID‑19 in hospitalized adults requiring oxygen, ventilation, or ECMO AND
• Patient previously approved for requested agent through plan’s PA process AND
• For atopic dermatitis: patient had clinical benefit and will continue standard maintenance therapies (e.g., emollients, good skin care) OR
• For polymyalgia rheumatica: patient had clinical benefit; if Kevzara, no neutropenia (ANC <1000/mm³), thrombocytopenia (<100,000/mm³), or AST/ALT >3× ULN OR
• For other indications: patient had clinical benefit with requested agent AND
• Prescriber is or consulted with a specialist appropriate to diagnosis AND
• Patient will not use combination with another immunomodulator OR if combination used, prescribing information allows and literature support provided AND
• Requested agent is eligible for continuation of therapy

Approval duration

12 months