Eohilia — Blue Cross Blue Shield of Texas

Initial criteria

• The patient has a diagnosis of eosinophilic esophagitis (EoE) confirmed by ALL of the following: chronic symptoms of esophageal dysfunction AND ≥15 eosinophils per high-power field on esophageal biopsy AND other causes ruled out.
• ONE of the following: (A) tried and had inadequate response to ONE standard corticosteroid therapy (swallowed budesonide nebulizer suspension or swallowed fluticasone via MDI) after at least 8 weeks, OR (B) intolerance or hypersensitivity to ONE standard corticosteroid therapy not expected with requested agent, OR (C) FDA labeled contraindication to ALL standard corticosteroid therapies not expected with requested agent, OR (D) tried and had inadequate response to ONE proton pump inhibitor after ≥8 weeks, OR (E) intolerance or hypersensitivity to ONE PPI, OR (F) FDA labeled contraindication to ALL PPIs.
• If patient has FDA labeled indication: ONE of the following – (A) patient’s age is within FDA labeling, OR (B) there is support for use at patient’s age.
• The prescriber is a specialist in area of diagnosis (e.g., gastroenterologist, allergist, immunologist), or has consulted with such specialist.
• The patient does NOT have any FDA labeled contraindications to requested agent.
• ONE of the following: (A) patient has NOT previously been treated with a 12‑week course of therapy with requested agent, OR (B) patient previously treated and there is support for additional course.

Reauthorization criteria

• Patient has previously been treated with a course of therapy with requested agent AND there is support for an additional course of therapy.

Approval duration

12 months (BCBSIL, BCBSMT, BCBSTX); others 3 months