IL-4 inhibitors — Blue Cross Blue Shield of Texas

Initial criteria

• Patient has ALL of the following: (A) Presence of ≥ 20 firm, nodular lesions AND (B) Pruritus lasting ≥ 6 weeks AND (C) History and/or signs of repeated scratching, picking, or rubbing
• ONE of the following: (A) BOTH of the following: (1) Patient diagnosed with stage 4 advanced, metastatic cancer and requested agent used to treat the cancer OR an associated condition; AND (2) Use is consistent with best practices supported by peer-reviewed, evidence-based literature and FDA approved; OR (B) ONE of the following: (1) Tried and had inadequate response to ONE at least medium-potency topical corticosteroid used in PN after at least 2 weeks OR (2) Has intolerance or hypersensitivity to ONE at least medium-potency topical corticosteroid used in PN OR (3) Has FDA labeled contraindication to ALL medium-, high-, and super-potency topical corticosteroids used in PN OR (4) Medication history indicates use of another biologic immunomodulator agent FDA labeled or supported in compendia for PN)

Approval duration

12 months