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​​Policy changes impacting biologics prescribed for autoimmune, asthma, or allergic conditions

October 20, 2022

​To ensure optimal management of high-cost biologics prescribed for complex autoimmune conditions (e.g., psoriasis, ulcerative colitis) and for severe asthma or allergic conditions (e.g., eosinophilic asthma, atopic dermatitis), the following changes went into effect October 1, 2022, for the Independence Blue Cross Select Drug Program® and Value Formulary:

  1. Submission of medical records is required to confirm medical necessity. Attestations are no longer accepted.
  2. Submission of medical record or paid claim history to support previous trial(s) with the pre-requisite(s) (when applicable). Attestations are no longer accepted.
  3. Objective measure(s) of efficacy is added to the reauthorization criteria (when applicable).
  4. Dosing and frequency does not exceed maximum FDA recommendation per indication requested.
    • ​​​​​​​New update for Dupixent, Fasenra, Nucala, and Xolair as of October 1, 2022.

These changes impact new starts and members seeking reauthorization as of October 1, 2022. Members with an active authorization will not experience interruption to therapy.

The following drugs are impacted by this update:

Brand NameGeneric Name
Actemra® SQtocilizumab
Arcalyst®
rilonacept
Cimzia®certolizumab
Cosentyxsecukinumab
Dupixent®dupliumab
Enbrel®etanercept
Fasenra®benralizumab
Humira®adalimumab
Kevzara®sarilumab 
Kineret®anakinra
Nucala®mepolizumab
Olumiant®baricitinib
Orencia®abatacept
Otezla®apremilast
Otrexup®, Rasuvo™, Reditrex™methotrexate
Rinovq™upadacitinib
Siliq™
brodalumab
Simponi®golimumab
Skyrizi™risankizumab-rzaa
Stelara®ustekinumab
Taltz™ixekizumab
Tremfya®guselkumab
Xeljanz [XR]®tofacitinib
Xolair®omalizumab
Zeposia®ozanimod

 

Please include pertinent chart notes when submitting prior authorization requests for these drugs. View instructions for submitting prior authorization here.

For additional information, please refer to the following drug coverage policies:

Dupilumab (Dupixent®)

Immune Modulating Therapies

Interleukin-5 (IL-5) Antibody Agents

Omalizumab (Xolair®)   

Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.​


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
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