Actemra — Blue Cross Blue Shield of Texas

Initial criteria

• Patient has hypersensitivity to, contraindication to, or lack of appropriateness for all Step 1 agents for the requested indication with documentation required OR patient currently stable on requested agent OR prerequisite biologic immunomodulator(s) discontinued or expected ineffective/unsafe/not in best interest or tried drug in same class futile.
• If Omvoh is requested for Crohn’s disease or ulcerative colitis, patient received or will receive Omvoh IV for induction therapy.
• If Entyvio is requested for Crohn’s disease or ulcerative colitis, patient received or will receive at least two doses of Entyvio IV therapy.
• If Skyrizi is requested for Crohn’s disease or ulcerative colitis, patient received or will receive Skyrizi IV for induction therapy.
• If Zymfentra is requested for Crohn’s disease or ulcerative colitis, patient received or will receive an infliximab IV product for induction therapy.
• If Tremfya is requested for ulcerative colitis, patient received or will receive Tremfya IV for induction therapy.
• Patient age within FDA labeling or supported for requested indication.
• For Cosentyx 300 mg maintenance dosing: (A) for moderate‑to‑severe plaque psoriasis ± psoriatic arthritis, dose 300 mg every 4 weeks; OR (B) for hidradenitis suppurativa, dose 300 mg q4weeks OR q2weeks after ≥3 months of 300 mg q4weeks failure; OR (C) for active psoriatic arthritis or ankylosing spondylitis, dose 300 mg q4weeks and prior inadequate response to 150 mg q4weeks ≥3 months.
• If Tremfya 200 mg requested, patient has Crohn’s disease or ulcerative colitis.
• If Omvoh 300 mg requested as maintenance, patient has Crohn’s disease.
• If Actemra requested for SSc‑ILD, request is for Actemra syringe (ACTpen not approvable).
• If Kevzara requested for pJIA, patient weight ≥ 63 kg.
• For atopic dermatitis, patient uses and will continue topical emollients/good skin care.
• Prescriber is or has consulted appropriate specialist by indication.
• Requested agent not used with another immunomodulatory unless prescribing info permits and supportive data provided.
• Patient has no FDA‑labeled contraindications to requested agent.
• If PI requires TB testing, patient tested and treated if positive.
• For Ohio fully insured or HIM Shop members, approval if no contraindication and indication is FDA‑labeled, compendia‑supported, or supported by two major peer‑reviewed articles.

Reauthorization criteria

• Request not for Olumiant or Actemra treatment of COVID‑19.
• Patient previously approved through plan prior authorization.
• For atopic dermatitis: patient has clinical benefit and will continue maintenance therapies.
• For polymyalgia rheumatica: patient has clinical benefit and if Kevzara requested, no neutropenia (ANC<1,000/mm3), no thrombocytopenia (<100,000/mm3), and no AST/ALT > 3×ULN.
• For other diagnoses: patient has clinical benefit with requested agent.
• Prescriber is or has consulted relevant specialist.
• Use not with another immunomodulator unless labeling allows and evidence supports combination.
• Agent eligible for continuation of therapy (all except Actemra) OR indication does not require prerequisite biologic, or agent is Step 1a, OR patient has stage IV advanced/metastatic cancer.

Approval duration

12 months (Rinvoq for atopic dermatitis 6 months; Siliq for psoriasis 16 weeks; Xeljanz/Xeljanz XR for UC induction 16 weeks)