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

Initial criteria

• Diagnosis of mild to moderate atopic dermatitis AND ALL of the following:
• - Body surface area (BSA) ≤ 20%
• - Patient is NOT immunocompromised
• - ONE of the following:
• • Tried and had inadequate response to at least a low-potency topical corticosteroid used for AD after ≥ 4 weeks OR
• • Intolerance or hypersensitivity to at least a low-potency topical corticosteroid used for AD OR
• • FDA labeled contraindication to ALL topical corticosteroids used for AD
• - ONE of the following:
• • Tried and had inadequate response to a topical calcineurin inhibitor used for AD after ≥ 6 weeks OR
• • Intolerance or hypersensitivity to a topical calcineurin inhibitor used for AD OR
• • FDA labeled contraindication to ALL topical calcineurin inhibitors used for AD
• - BOTH of the following:
• • Currently treated with topical emollients and practicing good skin care
• • Will continue the use of topical emollients and good skin care practices in combination with requested agent
• OR Diagnosis of nonsegmental vitiligo AND ALL of the following:
• - BSA ≤ 10%
• - ONE of the following:
• • Stage four advanced metastatic cancer use as documented and consistent with best practices, peer-reviewed evidence, and FDA approval OR
• • Vitiligo impacting areas OTHER THAN face, neck, axillary, or groin AND ONE of the following:
• – Tried and inadequate response to at least a medium-potency topical corticosteroid after ≥ 2 weeks OR
• – Intolerance/hypersensitivity to at least a medium-potency corticosteroid OR
• – FDA labeled contraindication to ALL medium-, high-, and super-potency corticosteroids OR
• • Vitiligo on face, neck, axillary, or groin AND ONE of the following:
• – Tried and inadequate response to a medium-potency topical corticosteroid after ≥ 2 weeks OR
• – Tried and inadequate response to topical calcineurin inhibitor OR
• – Intolerance/hypersensitivity to at least a medium-potency corticosteroid OR topical calcineurin inhibitor OR
• – FDA labeled contraindication to ALL medium-, high-, and super-potency corticosteroids AND ALL topical calcineurin inhibitors
• OR Patient has another FDA labeled indication for the requested agent AND:
• - Patient’s age is within FDA labeling for the indication OR there is support for use at patient’s age
• - Prescriber is a specialist in dermatology or consulted with one
• - ONE of the following:
• • NOT used in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR
• • If used in combination, both of the following:
• – Prescribing information does NOT limit combination use
• – Support for combination therapy provided (clinical trials, studies, guidelines)
• - No FDA labeled contraindications to the requested agent

Approval duration

12 months (BCBSIL and BCBSTX); 3 months for AD and 6 months for vitiligo for other plans