apremilast — Blue Cross Blue Shield of Texas

Initial criteria

• Continuation of therapy may be approved if: prescriber states patient has been treated with requested agent (not just samples) within past 90 days AND is at risk if therapy is changed.
• For new starts, ONE of the following diagnoses must apply:
• 1. Active psoriatic arthritis (PsA) AND ONE of the following:
• - Has tried and had an inadequate response to ≥1 conventional agent (cyclosporine, leflunomide, methotrexate, sulfasalazine) after at least 3 months OR
• - Has intolerance or hypersensitivity to ≥1 conventional agent OR
• - Has an FDA labeled contraindication to ALL conventional agents OR
• - Medication history indicates use of another biologic immunomodulator agent that is FDA labeled or compendia-supported for PsA.
• 2. Plaque psoriasis (PS) AND BOTH of the following:
• - Adult with mild to severe PS OR pediatric age ≥6 years with moderate to severe PS and weight ≥20 kg, AND
• - ONE of the following: inadequate response to ≥1 conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA [phototherapy], tacrolimus, tazarotene, topical corticosteroids) after ≥3 months OR intolerance/hypersensitivity to one OR contraindication to all OR medication history shows another biologic used for PS.
• 3. Behcet’s disease (BD) AND ALL of the following:
• - Active oral ulcers associated with BD,
• - ≥3 occurrences of oral ulcers within the last 12 months,
• - ONE of the following: inadequate response to ≥1 conventional agent (topical oral corticosteroids such as triamcinolone dental paste, colchicine) after adequate duration OR intolerance to one OR contraindication to all OR medication history indicates another biologic immunomodulator used for BD.