ustekinumab 90 mg product — Blue Cross Blue Shield of Texas

psoriatic arthritis

Preferred products

Patient received an ustekinumab IV product for induction therapy OR patient is new to therapy and will receive an ustekinumab IV product for induction therapy
If patient has an FDA labeled indication, then ONE of the following: (A) Patient’s age is within FDA labeling for the requested indication OR (B) There is support for using the requested agent for the patient’s age for the requested indication
If ustekinumab 90 mg product is requested, then ONE of: (A) Diagnosis of psoriasis AND weight >100 kg OR (B) Dual diagnosis of psoriasis AND psoriatic arthritis AND weight >100 kg OR (C) Diagnosis of Crohn’s disease or ulcerative colitis
Prescriber is a specialist in the area of the patient’s diagnosis or has consulted with one
ONE of the following: (A) Patient will NOT be using in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR (B) If using with another immunomodulatory agent, BOTH: (1) Prescribing information does NOT limit combination and (2) There is support for use of combination therapy (e.g., clinical trials, phase III studies, or guidelines required)
Patient does NOT have any FDA labeled contraindications to the requested agent
Patient has been tested for latent TB and if positive has begun therapy for latent TB

Patient previously approved for the requested agent through the plan’s Prior Authorization process (renewal must be for same strength as initial approval)
Patient has had clinical benefit with the requested agent
ONE of the following: (A) Requested agent is a preferred agent OR (B) Patient meets ONE of the following: (1) Tried and had inadequate response to THREE preferred agents for ≥6 months each OR (2) Tried and had inadequate response to TWO preferred agents for ≥6 months each and intolerance or hypersensitivity to ONE preferred agent not expected to occur with requested agent OR (3) Tried and had inadequate response to ONE preferred agent for ≥6 months and intolerance/hypersensitivity to TWO preferred agents not expected to occur with requested agent OR (4) Intolerance or hypersensitivity to THREE preferred agents not expected to occur with requested agent OR (C) Patient has FDA labeled contraindication to ALL preferred agents not expected with requested agent
Prescriber is a specialist in area of diagnosis or has consulted with one
ONE of the following: (A) Will NOT use in combination with another immunomodulatory agent OR (B) If combination used, BOTH: (1) Prescribing info does NOT limit combination and (2) There is support for combination therapy
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months