Biologic Immunomodulators (various targeted agents) — Blue Cross Blue Shield of Texas

Initial criteria

• Prescriber is a specialist in the area of the patient's diagnosis (e.g., rheumatologist for JIA, PsA, RA; gastroenterologist for CD, UC; dermatologist for PS, AD; pulmonologist, radiologist, pathologist, rheumatologist for SSc-ILD; allergist, immunologist for AD) or has consulted with a specialist
• ONE of the following regarding concomitant immunomodulatory therapy: (A) Patient will NOT use the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) If used in combination, BOTH of the following: (1) prescribing information does not limit combination use and (2) clinical support for combination therapy provided
• Patient does NOT have any FDA-labeled contraindications
• ONE of the following regarding latent tuberculosis (TB): (A) Prescribing information requires testing AND patient tested for latent TB and is treated if positive OR (B) Prescribing information does not require testing

Reauthorization criteria

• Request is NOT for use of Olumiant or Actemra for COVID-19 treatment
• If request is for alopecia areata, coverage is not excluded under benefit
• Patient has been previously approved through the plan’s Prior Authorization process
• Diagnosis-specific benefit: (A) For moderate to severe atopic dermatitis: patient had clinical benefit AND will continue standard maintenance therapy OR (B) For polymyalgia rheumatica: patient had clinical benefit AND if Kevzara, patient does NOT have neutropenia (ANC <1000/mm³), thrombocytopenia (platelet <100,000/mm³), or AST/ALT ≥3× ULN OR (C) Other diagnoses: patient had clinical benefit
• Prescriber is a specialist or has consulted with one
• ONE of the following regarding combination therapy: (A) Patient will NOT use with another immunomodulator OR (B) If used in combination, BOTH of the following: (1) prescribing information does not limit combination use AND (2) clinical support provided
• Step algorithm per indication: (A) Requested agent eligible for continuation of therapy (all agents except Actemra) OR (B) Step 1a/1b/2/3a/3b/3c logic met based on prior inadequate response, intolerance, hypersensitivity, contraindication, or clinical inappropriateness to required step agents per indication
• Additional dosing-specific criteria: (1) Cosentyx 300 mg maintenance: appropriate indication/dose met per diagnosis; (2) Tremfya 200 mg: patient has CD or UC; (3) Omvoh 300 mg maintenance: patient has CD; (4) Actemra for SSc-ILD: syringe formulation requested only
• Patient does NOT have any FDA-labeled contraindications

Approval duration

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