Anthem IL‑17 Monoclonal Antibodies Policy Update

Coverage Criteria for IL-17 Agents

Initial Therapy — Bimzelx (Plaque Psoriasis, Adults)

Covered when ALL of the following are met

Bimzelx - Plaque Psoriasis (Adults): Individual is 18 years of age or older with chronic moderate to severe plaque psoriasis AND either (1) plaque psoriasis involving ≥ 3% body surface area (BSA) OR (2) plaque psoriasis involving < 3% BSA but involving sensitive areas or areas that significantly impact daily function (eg, palms, soles, head/neck, genitalia).age >= 18; BSA >= 3% or sensitive area involvement

AAD 2019 referenced

Initial Therapy — Bimzelx (Psoriatic Arthritis, Adults)

Covered when ALL of the following are met

Bimzelx - Psoriatic Arthritis (Adults): Individual is 18 years of age or older with moderate to severe psoriatic arthritis AND the individual has had an inadequate response to, or is intolerant of, conventional therapy (nonbiologic DMARDs such as methotrexate, sulfasalazine, cyclosporine, or leflunomide) OR has a contraindication to these agents.age >= 18

ACR 2019 referenced

Continuation Therapy — Bimzelx

Covered when ALL of the following are met

Bimzelx - Continuation: Individual has been receiving and is maintained on a stable dose of Bimzelx AND there is clinically significant improvement or stabilization in clinical signs and symptoms of disease.stable dose with clinical improvement or stability

Applies across indications

Initial Therapy — Cosentyx (AS)

Covered when ALL of the following are met

Cosentyx - Ankylosing Spondylitis (AS): Individual is 18 years of age or older with moderate to severe ankylosing spondylitis AND the individual has had an inadequate response to or is intolerant of conventional therapy (eg, NSAIDs or nonbiologic DMARDs such as sulfasalazine) OR has a contraindication to NSAIDs or sulfasalazine.age >= 18

Continuation requires stable dose and clinical benefit

Initial Therapy — Siliq (Plaque Psoriasis, Adults)

Covered when ALL of the following are met

Siliq - Plaque Psoriasis (Adults): Individual is 18 years of age or older with chronic moderate to severe plaque psoriasis AND either (1) plaque psoriasis involving ≥ 3% BSA OR (2) plaque psoriasis involving < 3% BSA with sensitive area involvement; AND the individual has had an inadequate response to or is intolerant of phototherapy or systemic therapy (eg, acitretin, cyclosporine, methotrexate) OR has a contraindication to those therapies.age >= 18; BSA >=3% or sensitive area involvement

Brodalumab has boxed warning for suicidal ideation; REMS enrollment required

Initial Therapy — Taltz (AS, nr-axSpA, PsA)

Covered when ALL of the following are met

Taltz - Indications: Indications include: (A) Ankylosing spondylitis (AS): individual ≥18 years with moderate to severe AS AND inadequate response to or intolerance of conventional therapy (eg, NSAIDs or sulfasalazine) OR contraindication; (B) Non-radiographic axial spondyloarthritis (nr-axSpA): individual ≥18 years with moderate to severe nr-axSpA AND inadequate response to or intolerance of conventional therapy (eg, NSAIDs or sulfasalazine) OR contraindication; (C) Psoriatic arthritis (PsA): individual ≥18 years with moderate to severe PsA AND inadequate response to or intolerance of conventional therapy (nonbiologic DMARDs such as methotrexate, sulfasalazine, cyclosporine, or leflunomide) OR contraindication.age >= 18

ACR 2019, Deodhar 2020 referenced

nr-axSpA coverage

Initial approvals for indications are covered when ALL of the following are met

nr-axSpA criteria: Individual is 18 years of age or older with moderate to severe non-radiographic axial spondyloarthritis AND the individual has had an inadequate response to or is intolerant of conventional therapy (eg, NSAIDs or nonbiologic DMARDs such as sulfasalazine) OR has a contraindication to NSAIDs or sulfasalazine.age >= 18

Per ACR 2019, Deodhar 2020

Psoriatic arthritis coverage

Initial approvals for Psoriatic Arthritis

PsA criteria: Individual is 18 years of age or older with moderate to severe psoriatic arthritis AND the individual has had an inadequate response to or is intolerant of conventional therapy (nonbiologic DMARDs such as methotrexate, sulfasalazine, cyclosporine, or leflunomide) OR has a contraindication to these agents.age >= 18

Per ACR 2019

Plaque psoriasis coverage (Cosentyx IV)

Plaque psoriasis (pediatric and adult) coverage for Cosentyx IV

Cosentyx IV - Plaque Psoriasis (Pediatric & Adult): Individual is 6 years of age or older with moderate to severe plaque psoriasis defined as either (1) BSA ≥ 3% OR (2) BSA < 3% with involvement of sensitive or functionally important areas (eg, palms, soles, head/neck, genitalia); AND the individual has had an inadequate response to or is intolerant of phototherapy or other systemic therapy (eg, acitretin, cyclosporine, methotrexate) OR has a contraindication to those therapies.age >= 6; BSA >= 3% or sensitive area involvement

AAD 2019 referenced

Dosing and quantity limit rules

Quantity and dosing approval logic

Bimzelx quantity limits: Product-specific quantity limits apply; initiation and maintenance regimens (including loading dose allowances) are defined per presentation and strength and must match documented dosing schedule.see product-specific quantities in policy

Override rules and initial loading allowances described in policy (eg first 16 weeks loading allowances)

Cosentyx initiation and maintenance quantities: Initiation: may approve specified number of pens/syringes to cover loading doses within initial time window (examples include up to 5 single pens/syringes in first 35 days or up to 10 x 160 mg units in first 16 weeks as applicable). Maintenance: routine limit generally 1 unit per 28 days or approved 2-pack allowances per policy and indication; IV vial dosing and mg/kg limits (1.75 mg/kg, max 300 mg every 4 weeks) apply for IV formulation.time windows and counts specified; Cosentyx IV 1.75 mg/kg up to 300 mg q4w

See policy override and initiation tables

Covered when criteria met

Coverage is provided when agent-specific clinical criteria, step therapy, and quantity limits are met per documented clinical indications and continuation rules.

General: Member has one of the listed ICD-10 diagnoses relevant to the requested agent (eg, psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis) AND documentation demonstrates meeting BSA and prior therapy/step therapy requirements as specified for the agent AND requested quantity/dosing is within policy limits or an approved override.see ICD-10 lists, BSA thresholds, and step therapy tables

Specific agent criteria, step therapy, and quantity limits are defined in the corresponding sections of the policy

Requests proposing concurrent use of an IL-17 monoclonal antibody with other listed systemic immunomodulatory therapies or phototherapy are not approved. Specifically, combination use with phototherapy for psoriasis or psoriatic arthritis, topical or oral JAK inhibitors, ozanimod, etrasimod, apremilast, deucravacitinib, or biologic immunomodulators (including TNF antagonists, IL‑23 inhibitors, other IL‑17 inhibitors, vedolizumab, ustekinumab, abatacept, IL‑1/IL‑6 inhibitors, rituximab, or natalizumab) is excluded from coverage. This combination-use exclusion was clarified in the 11/14/2025 revision to explicitly apply to psoriasis and psoriatic arthritis and to reflect the updated list of disallowed agents.

At the policy level, IL‑17 agents (for example, secukinumab/Cosentyx) are explicitly prohibited from being used in combination with phototherapy for psoriasis or psoriatic arthritis and from concurrent use with the systemic therapies listed above (topical/oral JAK inhibitors, ozanimod, etrasimod, apremilast, deucravacitinib, and specified biologic immunomodulators). Requests that propose such combinations do not meet coverage criteria and may be denied.

The policy clarifies and expands the combination-use exclusions to include additional agents and to specify ‘‘biologic immunomodulators’’ by name. The phototherapy exclusion was revised to explicitly apply to both psoriasis and psoriatic arthritis. These clarifications are reflected in the document history and the exclusion text to ensure consistent application during benefit review.

Operationally, requests will be denied when the requested IL‑17 therapy is for an indication not listed in the policy, when required prior therapy or step‑therapy documentation is absent, or when the request proposes disallowed combinations (including phototherapy or the systemic agents enumerated in the exclusion list). Denials may also be issued if there is evidence of active tuberculosis, other active serious infections, or a history of recurrent infections without documentation supporting safe use.

Before initiating therapy with an IL‑17 agent, documentation of evaluation for latent tuberculosis is required: a tuberculin skin test (TST) or a CDC‑recommended equivalent must be performed and recorded unless the member is switching from another targeted immune modulator and has no new TB risk factors. Repeat TB testing is not required for ongoing therapy; absence of required TB testing at initiation may render the request non‑approvable.

Brodalumab (Siliq) is not approved for use in individuals with Crohn’s disease per the product label; the policy explicitly lists Crohn’s disease as a non‑approval condition for brodalumab and will deny requests where this diagnosis is present.

Coding and Clinical Thresholds

Coding (section header)mixed

No codes listed

Cosentyx HCPCSHCPCS

C9399	Unclassified drugs or biologicals [when specified as Cosentyx SC (secukinumab SC)]
J3247	Injection, secukinumab, intravenous, 1 mg [Cosentyx IV]
J3590	Unclassified biologics [when specified as Cosentyx SC (secukinumab SC)]

Bimzelx HCPCSHCPCS

C9399	Unclassified drugs or biologicals [when specified as Bimzelx (bimekizumab-bkzx)]
J3590	Unclassified biologics [when specified as Bimzelx (bimekizumab-bkzx)]

Taltz HCPCSHCPCS

C9399	Unclassified drugs or biologicals [when specified as Taltz (ixekizumab)]
J3590	Unclassified biologics [when specified as Taltz (ixekizumab)]

ICD-10 Diagnosis CodesICD-10

L40.0	Psoriasis vulgaris (plaque psoriasis)
L40.50-L40.59	Arthropathic psoriasis
L40.8-L40.9	Other, unspecified psoriasis
L73.2	Hidradenitis suppurativa
M08.80-M08.89	Juvenile arthritis, unspecified [enthesitis-related arthritis]
M45.0-M45.9	Ankylosing spondylitis
M45.A0-M45.AB	Non-radiographic axial spondyloarthritis

Taltz (ixekizumab) HCPCSHCPCS

C9399	Unclassified drugs or biologicals [when specified as Taltz (ixekizumab)]
J3590	Unclassified biologics [when specified as Taltz (ixekizumab)]

Siliq (brodalumab) HCPCSHCPCS

C9399	Unclassified drugs or biologicals [when specified as Siliq (brodalumab)]
J3590	Unclassified biologics [when specified as Siliq (brodalumab)]

ICD-10 Diagnosis codesICD-10

L40.0	Psoriasis vulgaris (plaque psoriasis)
L40.50-L40.59	Arthropathic psoriasis
L40.8-L40.9	Other, unspecified psoriasis
M45.0-M45.9	Ankylosing spondylitis
M45.A0-M45.AB	Non-radiographic axial spondyloarthritis

Body surface area threshold for moderate-severe plaque psoriasis

Moderate-severe plaque psoriasis threshold>= 3% body surface area (BSA)

Source guideline referenceAAD 2019 definition referenced in policy

Applies toAdult and pediatric plaque psoriasis indications where specified in agent criteria

Body surface area (BSA) for plaque psoriasis — alternate rule

Alternate BSA rule≥ 3% BSA OR < 3% BSA when involving sensitive areas (palms, soles, head/neck, genitalia) that significantly impact daily function

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for targeted immune modulators and IV biologic formulations. Provide clinical documentation to support the requested agent and indication; approvals are granted only when the medical necessity criteria in the policy are met.

Prior authorization submission must include diagnosis, prior therapy history, and rationale for non-preferred or non-standard agent.
Include HCPCS/NDC or other billing code if agent will be billed under unclassified drug/biologic codes (see callout on unclassified codes).

Step Therapy

Step Therapy / Preferred Agent Trial Requirement

Step therapy may apply before approval of non-preferred IV or injectable agents. The benefit plan may require use of one or more preferred agents (a trial of multiple products with the same active ingredient counts as a trial of ONE preferred agent).

For plaque psoriasis commercial requests, one preferred agent trial (and inadequate response/intolerance) is required unless the member is currently on Cosentyx IV or has documented reasons all preferred agents are not appropriate.

Background and Rationale

Interleukin‑17A inhibitors bind or neutralize IL‑17A and reduce IL‑17A‑mediated inflammation. These agents are FDA‑approved for multiple immune‑mediated conditions including plaque psoriasis, psoriatic arthritis, ankylosing spondylitis and non‑radiographic axial spondyloarthritis, with some agents having pediatric indications and others having additional approved uses (e.g., hidradenitis suppurativa for secukinumab per recent updates).

Definitions and Terms

Moderate to severe plaque psoriasis — key definition

DefinitionModerate to severe plaque psoriasis = involvement of ≥3% BSA or involvement of sensitive areas that significantly impact daily function (eg, palms, soles, head/neck, genitalia)

Guideline citedAmerican Academy of Dermatology (AAD) 2019

Applies toUsed as severity threshold for initial approval criteria across multiple agents in the policy

Inadequate response / intolerance — key definition

Definition of inadequate response/intoleranceFailure to achieve sufficient clinical improvement or inability to tolerate conventional therapy (eg, NSAIDs, methotrexate, sulfasalazine, cyclosporine, leflunomide) as documented in the medical record

Policy applicationRequired for approvals in PsA, nr-axSpA, AS, and plaque psoriasis when step therapy/prior therapy is specified

OpenPayer

Monoclonal Antibodies to Interleukin-17 (IL-17) — Clinical Coverage Criteria

Coverage Criteria for IL-17 Agents

Coding and Clinical Thresholds

Provider Actions, Prior Authorization & Documentation

Background and Rationale

Definitions and Terms