Otezla (apremilast) — Blue Cross Blue Shield of Texas

FDA labeled indications

Initial criteria

Patient has diagnosis meeting an FDA labeled indication OR a compendia supported indication (AHFS, DrugDex 1, 2a, or 2b, NCCN 1, 2a, or 2b recommended use)
If indication is Behçet’s disease, patient tried, intolerant, contraindicated, or had inadequate response to one conventional agent (e.g., azathioprine) OR use of another biologic immunomodulator FDA labeled for BD
Patient’s age is within FDA labeling for the requested indication OR agent use supported for patient’s age OR agent has compendia supported indication for patient’s age
Patient will NOT be using the requested agent with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR if combination, BOTH of: prescribing information does not limit combination use AND support (clinical trial, phase III study, or guideline) provided
ONE of: patient has mild severity plaque psoriasis OR prescriber is a specialist in patient's diagnosis area or has consulted with a specialist
Patient does NOT have any FDA labeled contraindications to the requested agent

Patient was previously approved for requested agent through plan’s prior authorization process
Patient has had clinical benefit with requested agent
Patient will NOT be using with another immunomodulatory agent OR if combination, BOTH: prescribing information does not limit combination AND support for combination therapy provided
ONE of: patient has mild severity plaque psoriasis OR prescriber is a specialist or has consulted a specialist
Patient does NOT have any FDA labeled contraindications to requested agent

12 months