Target Agent(s) (biologic immunomodulators) — Blue Cross Blue Shield of Texas

All indications supported in compendia

Preferred products

The request is NOT for use of Olumiant or Actemra in the treatment of coronavirus disease 2019 (COVID-19) in hospitalized adults requiring supplemental oxygen, noninvasive or invasive mechanical ventilation, or ECMO
ONE of the following: (A) The requested agent is eligible for continuation of therapy OR (B) The patient has an FDA labeled indication or an indication supported in compendia for the requested agent and route of administration
For continuation of therapy: the patient has been treated with the requested agent within the past 90 days (not on samples) and is at risk if therapy is changed
For rheumatoid arthritis: ONE of the following must apply: (1) Has tried and had an inadequate response to maximally tolerated methotrexate (≥3 months) OR (2) Has tried and had an inadequate response to one conventional agent (hydroxychloroquine, leflunomide, or sulfasalazine) (≥3 months) OR (3) Has intolerance or hypersensitivity to one conventional agent OR (4) Has FDA labeled contraindication to all conventional agents OR (5) Medication history indicates use of another biologic immunomodulator labeled or compendia supported for RA
If the request is for Simponi: ONE of the following must apply: (A) Will be taken in combination with methotrexate OR (B) The patient has intolerance, contraindication, or hypersensitivity to methotrexate
For psoriatic arthritis: patient must have an active disease diagnosis

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process (ustekinumab renewal must be for the same strength)
The patient has had clinical benefit with the requested agent
If client has preferred agents, then ONE of the following: (A) Requested agent is preferred OR (B–J) patient meets exceptions including trial/failure/intolerance/contraindication to THREE preferred agents, metastatic cancer considerations, stability on current therapy, or other medical necessity rationales with required documentation
The prescriber is a specialist in the area of the patient’s diagnosis or has consulted a specialist
The patient will not use the requested agent in combination with another immunomodulatory agent unless labeling permits and supportive clinical evidence is provided
The patient does not have any FDA labeled contraindications

12 months