Opzelura (ruxolitinib phosphate) cream 1.5 % — Blue Cross Blue Shield of Texas

any indication when member resides in Ohio and plan is Fully Insured or HIM Shop (SG)

Initial criteria

Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
Patient has no FDA labeled contraindications
ONE of the following:
- Has another FDA labeled indication for the requested agent and route of administration OR
- Has another indication supported in compendia for the agent and route OR
- Prescriber submitted two peer-reviewed medical journal articles (acceptable randomized, double-blind, placebo-controlled trials) supporting requested use as generally safe and effective
Non-oncology compendia allowed: DrugDex level 1, 2A, 2B or AHFS-DI (supportive narrative)
Oncology compendia allowed: NCCN 1 or 2A, AHFS-DI (supportive narrative), DrugDex level 1, 2A, 2B, Clinical Pharmacology (supportive narrative), or LexiDrugs evidence level A

12 months