Tremfya — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Administration or hypersensitivity to three Step 1 agents for the requested indication OR the patient has an FDA labeled contraindication to all Step 1 agents for the requested indication OR both of the following: all Step 1 agents are not clinically appropriate for the patient AND the prescriber has provided a complete list of previously tried agents for the indication OR the patient is currently stable on the requested agent OR the required prerequisite biologic immunomodulator agent(s) were discontinued due to lack of efficacy, diminished effect, or adverse event OR the prerequisite agent(s) are expected to be ineffective or harmful OR not in the patient's best interest OR patient failed another drug in the same class.
• If Omvoh is requested for Crohn's disease or ulcerative colitis: patient has received or will receive Omvoh IV for induction.
• If Entyvio is requested for Crohn's disease or ulcerative colitis: patient has received or will receive at least 2 doses of Entyvio IV.
• If Skyrizi is requested for Crohn's disease or ulcerative colitis: patient has received or will receive Skyrizi IV for induction.
• If Zymfentra is requested for Crohn's disease or ulcerative colitis: patient has received or will receive an infliximab IV product for induction.
• If Tremfya is requested for ulcerative colitis: patient has received or will receive Tremfya IV for induction.
• Patient age is within FDA labeling for requested indication OR supported for the requested age.
• If Cosentyx 300 mg is requested as maintenance dosing: criteria by diagnosis and dosing schedule specified (plaque psoriasis, hidradenitis suppurativa, psoriatic arthritis, ankylosing spondylitis).
• If Tremfya 200 mg: diagnosis of Crohn's disease or ulcerative colitis.
• If Omvoh 300 mg: diagnosis of Crohn's disease.
• If Actemra for systemic sclerosis associated interstitial lung disease: only Actemra syringe allowed.
• If Kevzara for polyarticular juvenile idiopathic arthritis: patient weight ≥ 63 kg.
• If moderate-to-severe atopic dermatitis: patient is and will continue use of topical emollients and good skin care.
• Prescriber is appropriate specialist or has consulted with one.
• Patient will not use with another immunomodulatory agent unless supported and allowed per prescribing information.
• Patient does not have any FDA labeled contraindications.
• If required, latent TB testing has been completed and treated if positive.
• For Ohio HIM fully insured members: criteria for alternate indications supported by FDA labeling, compendia, or 2 major peer-reviewed studies.

Reauthorization criteria

• Request not for use of Olumiant or Actemra for COVID-19 hospitalization.
• Patient previously approved for the requested agent through prior authorization.
• For moderate to severe atopic dermatitis: patient had clinical benefit and will continue topical therapies.
• For polymyalgia rheumatica: patient had clinical benefit and if Kevzara, no neutropenia, thrombocytopenia, or LFT elevations ≥3x ULN.
• For all other indications: patient had clinical benefit with requested agent.
• Prescriber is a specialist or has consulted with one.
• Patient will not use with another immunomodulator unless supported per labeling and evidence submitted.
• Agent eligible for continuation of therapy (all except Actemra) OR steps met per Step table for continued therapy.

Approval duration

12 months (Rinvoq for AD: 6 months; Siliq for PS: 16 weeks; Xeljanz/Xeljanz XR for UC induction: 16 weeks)