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Zeposia — Blue Cross Blue Shield of Texas

relapsing forms of multiple sclerosis (MS)

Preferred products

  • Adalimumab-aaty
  • Adalimumab-adaz
  • Hadlima
  • Humira
  • Simlandi
  • Omvoh
  • Selarsdi
  • Simponi
  • Steqeym
  • Skyrizi
  • Stelara
  • Tremfya
  • Velsipity
  • Xeljanz
  • Xeljanz XR

Initial criteria

  • ONE of the following: A. Eligible for continuation of therapy – prescriber states patient has been treated with requested agent within past 90 days AND is at risk if therapy is changed; OR B. Meets all indication requirements below
  • For MS: patient has relapsing form of MS AND ONE of: (1) requested agent not used with another disease modifying agent (DMA); OR (2) used with Mavenclad (cladribine) with support for combination use (e.g., relapse between cycles)
  • For UC: patient has moderately to severely active ulcerative colitis AND ALL of the following:
  • 1. ONE of: (A) tried and had inadequate response to ONE conventional agent (6‑mercaptopurine, azathioprine, balsalazide, corticosteroids, cyclosporine, mesalamine, sulfasalazine) for ≥3 months; OR (B) severely active UC; OR (C) intolerance/hypersensitivity to ONE conventional agent; OR (D) FDA-labeled contraindication to ALL conventional agents; OR (E) medication history indicates use of another biologic immunomodulator agent for UC
  • 2. ONE of: (A) currently stable on Zeposia (chart notes required); OR (B) tried and had inadequate response to at least TWO Step 1 immunomodulatory agents (chart notes required); OR (C) TWO Step 1 immunomodulatory agents discontinued for lack of efficacy/effectiveness/adverse event; OR (D) intolerance/hypersensitivity to at least TWO Step 1 immunomodulatory agents; OR (E) FDA-labeled contraindication to ALL Step 1 immunomodulatory agents; OR (F) TWO Step 1 agents expected to be ineffective, cause adherence barrier, worsen comorbidity, impair functioning, or cause harm (chart notes required); OR (G) TWO Step 1 agents not in best interest based on medical necessity; OR (H) tried another prescription drug in same class/mechanism as TWO Step 1 agents discontinued for lack of efficacy or adverse event (chart notes required)
  • 3. ONE of: (A) requested agent not used in combination with other immunomodulatory (e.g., TNF inhibitors, JAK inhibitors, IL‑4 inhibitors); OR (B) if used with immunomodulatory, BOTH (1) prescribing information does not limit use with another immunomodulatory agent, AND (2) documentation supports combination therapy (copy of clinical evidence required)
  • Patient’s age within FDA labeling for indication OR supported for use by clinical evidence
  • Electrocardiogram performed within 6 months prior to initiating treatment
  • Prescriber is specialist (e.g., neurologist for MS, gastroenterologist for UC) or has consulted with one
  • Patient has no FDA-labeled contraindications to Zeposia

Approval duration

12 months