Otezla (apremilast) prior authorization and coverage policy
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Defines medical necessity criteria, required documentation, prescriber specialty, quantity limits, dosing guidance, continuation criteria, and exclusions for coverage of Otezla (apremilast) for plaque psoriasis, psoriatic arthritis, Behçet's disease oral ulcers, and immune checkpoint inhibitor-related toxicity for Wellmark Blue Cross and Blue Shield.
Reviewed April 2026; revised April 2026 with current effective date June 11, 2026.
Coverage Summary
Coverage stance: covered_with_criteria. Scope summary: Defines medical necessity criteria, required documentation, prescriber specialty requirements, quantity limits and dosing guidance, continuation criteria, and exclusions for coverage of Otezla (apremilast) for plaque psoriasis, psoriatic arthritis, Behçet's disease oral ulcers, and immune checkpoint inhibitor-related toxicity for Wellmark Blue Cross and Blue Shield. Covered indications: the policy lists 4 FDA-approved indications — adult plaque psoriasis; pediatric plaque psoriasis (≥6 years and ≥20 kg); adult and pediatric active psoriatic arthritis (≥6 years and ≥20 kg); and adults with oral ulcers associated with Behçet's disease — plus 1 compendial indication (immune checkpoint inhibitor-related toxicity). Effective date: June 11, 2026. Policy number: 05.02.11.
Initial Therapy Criteria (FDA-Approved and Compendial Indications)
Initial Therapy Criteria (FDA-Approved and Compendial Indications)
Covered when ALL of the following are met:
Provider Actions — Documentation & Prescriber Specialty
Prior authorization required
Prior authorization is required. For initial requests for plaque psoriasis and psoriatic arthritis submit chart notes, medical record documentation, or claims history supporting previous medications tried and response; if a therapy is not advisable, include documentation of the clinical reason to avoid that therapy. For continuation requests submit chart notes or medical record documentation supporting a positive clinical response to therapy. For Behçet's disease initial requests, submit chart notes, medical record documentation, or claims history supporting previous medications tried and response.
- Initial requests (PsO and PsA): chart notes, medical record documentation, or claims history supporting previous medications tried and response; documentation if therapy is not advisable.
- Continuation requests: chart notes or medical record documentation supporting positive clinical response to therapy.
- Behçet's disease (initial only): chart notes, medical record documentation, or claims history supporting previous medications tried and response.
Prescriber specialty requirement (initial approvals)
For initial approvals, the medication must be prescribed by or in consultation with a specialist appropriate to the indication. Prescriber specialty requirements are listed by indication below.
- Plaque psoriasis: dermatologist
- Psoriatic arthritis: rheumatologist or dermatologist
- Behçet's disease: rheumatologist
- Immune checkpoint inhibitor-related toxicity: dermatologist, hematologist, or oncologist
Quantity limits and dosing adherence
Approvals are subject to dosing and quantity limits per FDA labeling. Adhere to starter pack limits and tablet quantity limits as specified.
- Otezla starter pack: Quantity Limit = 2 packs (110 tablets) per lifetime
- Otezla 20 mg tablets: Quantity Limit = 60 per 30 days
- Otezla 30 mg tablets: Quantity Limit = 60 per 30 days (pediatric 20 kg to <50 kg)
- Otezla XR starter pack: Quantity Limit = 1 pack per lifetime
- Otezla XR 75 mg tablets: Quantity Limit = 30 per 30 days
Concomitant therapy exclusion
Concomitant use of Otezla with any other biologic drug or targeted synthetic drug for the same indication is not allowed and may be denied/considered not medically necessary.
Continuation / Renewal Criteria
Continuation / Renewal Criteria
Authorization of 12 months may be granted when ALL of the following are met
- Approved indication use: Member is using the requested medication for the approved indication
- Positive clinical response: Member achieves or maintains positive clinical response as evidenced by indication-specific measures
Definitions include BSA reduction, joint counts, dactylitis, enthesitis, functional status, CRP
Plaque psoriasis response examples
- BSA reduction: Reduction in body surface area (BSA) affected from baseline
- Improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling, burning, cracking, pain)
Psoriatic arthritis response examples
- Swollen joints: Improvement in number of swollen joints
- Tender joints: Improvement in number of tender joints
- Dactylitis: Improvement in dactylitis
- Enthesitis: Improvement in enthesitis
- Axial disease: Improvement in axial disease
- Skin and/or nail: Improvement in skin and/or nail involvement
- Functional status: Improvement in functional status
- CRP: Improvement in C-reactive protein (CRP)
- Behçet's disease and immunotherapy-related toxicity: For Behçet's disease and immunotherapy-related toxicity: maintenance or improvement in signs and symptoms / low disease activity
Exclusions / Not Medically Necessary
General Exclusions / Not Medically Necessary
- Concomitant use prohibition: Concomitant use with any other biologic drug or targeted synthetic drug for the same indication is not allowed
- Not medically necessary statement: Otezla is considered not medically necessary for members who do not meet the criteria set forth above
- Samples/assistance program note: Members receiving medication as samples or via manufacturer's patient assistance program must meet initial approval criteria
Applicable Codes & Quantity Limits
| N/A | Policy states to use appropriate CPT, HCPCS, Revenue, and ICD diagnostic codes; specific codes not listed |
| Otezla starter pack | Quantity Limit = 2 packs (110 tablets) per lifetime |
| Otezla 20 mg tablets | Quantity Limit = 60 per 30 days |
| Otezla 30 mg tablets | Quantity Limit = 60 per 30 days (pediatric 20 kg to <50 kg) |
| Otezla XR starter pack | Quantity Limit = 1 pack per lifetime |
| Otezla XR 75 mg tablets | Quantity Limit = 30 per 30 days |
Clinical Evidence & References
Evidence references cited in the policy include the primary product reference: Otezla [package insert], Amgen Inc.; August 2025. Guideline references cited include Joint AAD-NPF guidance, GRAPPA recommendations, EULAR recommendations, ACR/NPF guidance, and NCCN guidelines; the policy also notes relevant clinical trials are cited (policy references include randomized trials and ClinicalTrials.gov entries).
Definitions
Positive clinical response: Improvement or low disease activity as evidenced by indication-specific measures (e.g., reduction in body surface area [BSA], improvement in signs and symptoms such as itching/redness/flaking/scaling, reduction in number of swollen or tender joints, improvement in dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, or C-reactive protein [CRP]).
Revision History
Reviewed April 2026; revised April 2026.
Revised April 2026 with current effective date June 11, 2026.
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