CurrentBlue Cross Blue Shield - IowaPolicy 05.02.11

Otezla (apremilast) prior authorization and coverage policy

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.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyOtezla (apremilast) prior authorization and coverage policy

Policy CodePolicy 05.02.11

Change TypeClarified / Reviewed

Effective DateJun 11, 2026

Next Review Date

Key ActionPrior authorization is required with submission of chart notes or medical record documentation supporting prior therapies and response for initial requests; continuation requests require documentation of positive clinical response.

SourceLink

POLICY UPDATE CHANGES

Reviewed April 2026; revised April 2026 with current effective date June 11, 2026.

4Covered Indications (FDA-approved listed)

1Compendial Indications listed

5Prescriber specialties required (by indication)

5Quantity limit entries

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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.

Quick facts and thresholds

Pediatric age/weight threshold≥ 6 years and ≥ 20 kg

Authorization duration12 months (authorization may be granted when criteria met)

Policy statusCURRENT

Last review dateApril 2026

Effective dateJune 11, 2026

Provider Actions — Documentation & Prescriber Specialty

Prior Authorization

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.

Documentation Required

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

Billing Rule

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

Denial Risk

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

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
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

Procedures and Billing Codesmixed

N/A	Policy states to use appropriate CPT, HCPCS, Revenue, and ICD diagnostic codes; specific codes not listed

Drug and Quantity Limit Identifiers (informational)NDC

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