IL-4 inhibitors — Blue Cross Blue Shield of Texas

Initial criteria

• Diagnosis confirmed by ALL of the following: (A) Chronic symptoms of esophageal dysfunction AND (B) ≥ 15 eosinophils per high-power field on esophageal biopsy AND (C) Other causes that may be responsible for or contributing to symptoms and esophageal eosinophilia ruled out
• Patient has ONE of the following: (A) Tried and had inadequate response to ONE standard corticosteroid therapy (budesonide oral suspension, swallowed budesonide nebulizer suspension, or swallowed fluticasone from MDI) used in treatment of EoE after at least 8 weeks OR (B) Has intolerance or hypersensitivity to ONE standard corticosteroid therapy used in EoE OR (C) Has FDA labeled contraindication to ALL standard corticosteroid therapies used in EoE OR (D) Tried and had inadequate response to ONE proton pump inhibitor (PPI) used in treatment of EoE after at least 8 weeks OR (E) Has intolerance or hypersensitivity to ONE PPI used in EoE OR (F) Has FDA labeled contraindication to ALL PPIs used in treatment of EoE

Approval duration

12 months