CurrentBlue Cross Blue Shield - IowaPolicy 05.02.15

Taltz (ixekizumab) — prior authorization and coverage criteria

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Defines prior authorization, clinical criteria, and coverage rules for Taltz for plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis for Wellmark/Blue Cross Blue Shield members.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyTaltz (ixekizumab) — prior authorization and coverage criteria

Policy CodePolicy 05.02.15

Change TypeNo material change

Effective DateMay 29, 2026

Last ReviewApr 29, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization with required documentation and prescriber specialty restrictions before initiating therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentBlue Cross Blue Shield - IowaPolicy 05.02.15

Taltz (ixekizumab) — prior authorization and coverage criteria

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Sign up for Blue Cross Blue Shield - Iowa Policy 05.02.15 alerts

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Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyTaltz (ixekizumab) — prior authorization and coverage criteria

Policy CodePolicy 05.02.15

Change TypeNo material change

Effective DateMay 29, 2026

Last ReviewApr 29, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization with required documentation and prescriber specialty restrictions before initiating therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥6 yearsminimum age for plaque psoriasis coverage

12 monthstypical authorization duration

2 preferredrequired preferred trials

TB test within 12 monthsTB screening requirement

Coverage and Medical Necessity Criteria

Initial Approval Criteria

Criteria for initial approval apply when at least ONE of the listed conditions for the indication is met.

Psoriatic arthritis - initial: At least ONE: (a) Member has had an inadequate response to treatment or intolerable adverse event with Cosentyx and another of the preferred products (Enbrel, Adalimumab-aacf, Rinvoq, Simponi, Skyrizi, Otezla, Otulfi (ustekinumab-aauz), Tremfya, Xeljanz/Xeljanz XR); OR (b) Member has a clinical reason to avoid TNF-inhibitors (Enbrel, Adalimumab-aacf, Simponi) (See Appendix A) AND has had an inadequate response to treatment or intolerable adverse event with Cosentyx and another of the preferred products (Skyrizi, Otezla, Otulfi (ustekinumab-aauz), Tremfya, Rinvoq, Xeljanz/Xeljanz XR); OR (c) Member is currently receiving treatment with the requested product through insurance (excludes samples or manufacturer's PAP) and experiencing a positive therapeutic outcome.1 of list

See Appendix A for clinical reasons to avoid TNF inhibitors.

Plaque psoriasis (adults) - initial: At least ONE: (a) Member has had an inadequate response to treatment or intolerable adverse event with Cosentyx and another of the preferred products (Adalimumab-aacf, Enbrel, Otezla, Skyrizi, Otulfi (ustekinumab-aauz), Tremfya); OR (b) Member has a clinical reason to avoid Enbrel and Adalimumab-aacf (See Appendix A) AND has had an inadequate response to treatment or intolerable adverse event with Cosentyx and another of the preferred products (Otezla, Skyrizi, Otulfi (ustekinumab-aauz), Tremfya); OR (c) Member is currently receiving treatment with the requested product through insurance (excludes samples or manufacturer's PAP) and experiencing a positive therapeutic outcome.1 of list

Adult-specific preferred product list.

Plaque psoriasis (pediatrics) - initial: At least ONE: (a) Member has had an inadequate response to treatment or intolerable adverse event with Cosentyx and another of the preferred products (Enbrel and Otulfi (ustekinumab-aauz)); OR (b) Member is currently receiving treatment with the requested product through insurance (excludes samples or manufacturer's PAP) and experiencing a positive therapeutic outcome.1 of list

Pediatric-specific preferred product list.

Ankylosing spondylitis - initial: At least ONE: (a) Member has had an inadequate response to treatment or intolerable adverse event with Cosentyx and another of the preferred products (Enbrel, Adalimumab-aacf, Rinvoq, Simponi, Xeljanz/Xeljanz XR); OR (b) Member has a clinical reason to avoid TNF-inhibitors (Enbrel, Adalimumab-aacf, Simponi) (See Appendix A) AND has had an inadequate response to treatment or intolerable adverse event with TWO of the preferred products (Cosentyx and Xeljanz or Rinvoq); OR (c) Member is currently receiving treatment with the requested product through insurance (excludes samples or manufacturer's PAP) and experiencing a positive therapeutic outcome.1 of list

See Appendix A for TNF avoidance reasons.

Non-radiographic axial spondyloarthritis - initial: At least ONE: (a) Member has had an inadequate response to treatment or intolerable adverse event with one of the preferred products (Cosentyx and Rinvoq); OR (b) Member is currently receiving treatment with the requested product through insurance (excludes samples or manufacturer's PAP) and experiencing a positive therapeutic outcome.1 of list

Submission of chart notes required for outcomes or contraindications.

Authorization and Continuation Criteria

Covered when ALL of the following for continuation or authorization duration are met (per indication groups below).

Plaque psoriasis - authorization: Authorization of 12 months may be granted for members ≥6 years who previously received a biologic/targeted synthetic for plaque psoriasis OR when any of: crucial body areas affected (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas); ≥10% BSA affected; OR ≥3% BSA affected AND inadequate response or intolerance to phototherapy (e.g., UVB, PUVA) or systemic non-biologic agents (methotrexate, cyclosporine, acitretin) OR clinical reason to avoid these therapies.N/A

See Appendix B for reasons to avoid conventional agents.

Psoriatic arthritis - authorization: Authorization of 12 months may be granted when either: (a) mild to moderate disease with inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD at adequate dose/duration OR intolerance/contraindication to those agents OR presence of enthesitis or predominantly axial disease; OR (b) severe disease.1 of list

Prior biologic/targeted synthetic use may support approval.

AS and non-radiographic axSpA — continuation criteria

Authorization of 12 months may be granted when members achieve or maintain positive clinical response demonstrated by improvement in at least one of the following from baseline:

AS/axSpA response criteria: Improvement in at least ONE: functional status; total spinal pain; inflammation (e.g., morning stiffness); swollen joints; tender joints; or C-reactive protein (CRP).improvement from baseline

Authorization for 12 months if any listed improvement is met

Universal pre-initiation requirements

For all indications, the following must be met before initiating therapy:

TB screening and concomitant use: Documented negative tuberculosis (TB) test (TST or IGRA) within 12 months prior to initiation for persons naïve to biologic or targeted synthetic drugs; AND member must not be using another biologic or targeted synthetic drug for the same indication.negative TB test within 12 months

If TB screening is positive, further testing to exclude active disease is required (e.g., chest x-ray); do not administer drug for active TB; treat latent TB before initiation.

This medical policy may not apply to members covered under the Federal Employee Program (FEP). Benefit determinations for FEP members are made separately according to the applicable FEP contract and are not governed by this policy.

Do not administer Taltz to members with active tuberculosis (TB) infection. If TB screening is positive, further evaluation to exclude active disease (for example, chest x‑ray) is required; latent TB must be treated prior to initiating therapy. Additionally, Taltz is considered not medically necessary for members who do not meet the policy’s stated criteria.

Taltz is considered not medically necessary for members who do not meet the clinical criteria set forth in this policy for the requested indication.

For all indications, initiation of Taltz requires a documented negative TB test (TST or IGRA) within the prior 12 months for patients naïve to biologic or targeted‑synthetic therapies associated with increased TB risk. Taltz is also considered not medically necessary if the member is using another biologic or targeted‑synthetic drug for the same indication (concomitant use).

Billing and Coding Guidance

Provider CPT/HCPCS guidancemixed

No codes listed

Prior Authorization, Documentation, and Prescriber Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests for Taltz. Initial approvals must be submitted by an appropriate prescriber specialty or include documentation of consultation per the prescriber specialty requirements below.

Prior authorization required
Prescriber specialty required for initial approvals

Prior Authorization

Authorization Period and Dosing Limits

Prior authorization approvals may be granted for up to 12 months for members who achieve or maintain a positive clinical response. Approvals are subject to quantity limits and dosing/initiation supply limits as specified by indication (see Quantity Limits).

Authorization period: up to 12 months when clinical response achieved/maintained
Approvals subject to dosing and initiation supply limits

Key Definitions and Clinical Response Metrics

FDA-Approved Indications

Plaque psoriasisModerate to severe plaque psoriasis in patients aged 6 years and older who are candidates for systemic therapy or phototherapy

Psoriatic arthritisAdult patients with active psoriatic arthritis

Ankylosing spondylitisAdult patients with active ankylosing spondylitis

Non‑radiographic axial spondyloarthritis (nr‑axSpA)Adult patients with active non‑radiographic axial spondyloarthritis with objective signs of inflammation

Positive clinical response

DefinitionImprovement or maintenance of low disease activity demonstrated by measures such as functional status, total spinal pain, inflammation (e.g., morning stiffness), swollen or tender joints, or C‑reactive protein (CRP)

Background and Drug Overview

Taltz (ixekizumab) is an interleukin‑17A antagonist indicated for several immune‑mediated dermatologic and rheumatologic conditions, including moderate to severe plaque psoriasis (in patients aged 6 years and older), psoriatic arthritis, ankylosing spondylitis, and non‑radiographic axial spondyloarthritis. This policy aligns use of Taltz to FDA‑approved indications and clinical selection criteria, and directs appropriate prior authorization, prescriber specialty, documentation, and trial‑of‑therapy requirements to ensure appropriate patient selection.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyTaltz (ixekizumab) — prior authorization and coverage criteria

Policy CodePolicy 05.02.15

Change TypeNo material change

Effective DateMay 29, 2026

Last ReviewApr 29, 2026

Next Review DateApr 1, 2026

Key ActionObtain prior authorization with required documentation and prescriber specialty restrictions before initiating therapy.

SourceLink

On This Page

Ankylosing spondylitis and nr-axSpA - authorization: Authorization of 12 months may be granted when either: (a) inadequate response to at least two NSAIDs; OR (b) intolerance or contraindication to two or more NSAIDs.1 of list

Applies to adult members; prior biologic/targeted synthetic use may support approval.

Continuation criteria general: Continuation requires documentation of positive clinical response, such as reduced BSA or improvement in signs and symptoms (e.g., itching, redness, flaking, scaling, burning, cracking, pain) for plaque psoriasis; for arthritides, documentation supporting positive clinical response is required.N/A

See chunks 16-17 for examples of response measures.

Documentation Required

Required Documentation for Prior Authorization

Initial prior authorization requests must include chart notes or medical record documentation as specified by indication. For plaque psoriasis include affected area(s) and body surface area (BSA). For ankylosing spondylitis, nr-axSpA, and psoriatic arthritis include prior medications tried, responses, or clinical rationale to avoid therapies when applicable.

Plaque psoriasis: chart notes documenting affected areas and BSA
AS/axSpA/PSA: chart notes, prior medication history and response or clinical rationale to avoid therapy

Documentation Required

Supporting Clinical Documentation

When applicable, submit supporting clinical documentation such as chart notes detailing outcomes of prior treatments, intolerable adverse events, contraindications, or reasons preferred products cannot be used. For continuation requests submit documentation of decreased BSA or clinical improvement/positive response.

Chart notes documenting outcomes, adverse events, contraindications, or exclusions to preferred products
Continuation: documentation of decreased BSA or improved signs/symptoms

Documentation Required

Non‑Formulary Documentation

Non‑formulary exception requests must include documentation that covered formulary alternatives are ineffective, not tolerated, or contraindicated. Provide chart notes showing prior treatment failure, severity of adverse events (if any), dosage and duration of prior treatments, or specific contraindications to formulary alternatives. The requested use must be for an FDA‑approved or compendia‑supported indication and dosing must align with labeling or compendia guidance.

Document why all covered formulary alternatives are inappropriate (failure, intolerance, or contraindication)
Include chart notes with prior treatment details: dosage, duration, and adverse event severity
Indication must be FDA‑approved or compendia supported and dosing within labeling

Step Therapy

Preferred-Product Trial Requirement

Policy requires trial of preferred products before approval of non‑preferred products for most indications. For many indications a trial of Cosentyx plus at least one other preferred agent is required, unless there is documented intolerance, contraindication, or the member is currently benefiting from the non‑preferred therapy.

Preferred‑product trial typically requires Cosentyx and another preferred product
Exceptions: clinical reason to avoid preferred products or current positive therapeutic outcome on requested product

Step Therapy

Formulary Alternative Trial Requirement

For non‑formulary approvals, the policy requires trial/failure or contraindication to covered formulary alternatives prior to coverage of the non‑formulary product. Documentation must include prior therapy trial details (agents tried, dose, duration, response, or adverse events) and rationale why alternatives are unsuitable.

Trial/failure or contraindication to covered formulary alternatives required for non‑formulary approval
Provide specific prior therapy details and rationale why alternatives cannot be used

AS/nr‑axSpA continuation standardAuthorization of 12 months may be granted when a member achieves or maintains positive clinical response as evidenced by improvement in any one listed measure from baseline

Documentation requirementChart notes must demonstrate improvement in at least one specific measure (e.g., reduced spinal pain, improved function, decreased CRP) to support continuation