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Zeposia (ozanimod) — Blue Cross Blue Shield of Oklahoma

ulcerative colitis

Initial criteria

  • The member resides in Ohio
  • The plan is Fully Insured or HIM Shop (SG)
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • ONE of the following: the patient has another FDA labeled indication for the requested agent and route of administration OR the patient has another indication that is supported in compendia for the requested agent and route of administration OR the prescriber has submitted TWO peer-reviewed journal articles (from JAMA, NEJM, Lancet, etc.) supporting the proposed use as generally safe and effective (case studies not acceptable)
  • Non-oncology compendia allowed: DrugDex level 1, 2A or 2B, AHFS-DI (narrative text supportive)
  • Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (narrative text supportive), DrugDex level 1, 2A, or 2B, Clinical Pharmacology (narrative text supportive), LexiDrugs evidence level A, or peer-reviewed medical literature

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 prescriber is a specialist in the area of the patient’s diagnosis or has consulted with a specialist in the area of the patient’s diagnosis
  • ONE of the following:
  • A. The patient has a diagnosis of multiple sclerosis AND ONE of the following: (1) The patient will NOT be using the requested agent in combination with another disease modifying agent (DMA) for the requested indication OR (2) The patient will use the requested agent in combination with another DMA (Mavenclad/cladribine) AND there is support for the combination (e.g., relapse between Mavenclad cycles)
  • B. The patient has a diagnosis of ulcerative colitis AND ONE of the following: (1) The patient will NOT use the requested agent in combination with an immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (2) The patient will use it in combination with another immunomodulatory agent AND (A) the prescribing information does NOT limit such use AND (B) there is supporting evidence (cited clinical trials, phase III studies, guidelines)
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months