CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Siliq (brodalumab) for Plaque Psoriasis

Customize your policy alerts

Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

Get alerted when Policy GA-MED-P-366579 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs pharmacy prior authorization and continued coverage of Siliq (brodalumab) for CareSource Georgia Medicaid members with moderate to severe plaque psoriasis. It specifies initial authorization requirements, dosing and quantity limits, reauthorization requirements, and non-medically necessary uses.

Policy Summary

PayerCareSource Georgia

PolicySiliq (brodalumab) for Plaque Psoriasis

Policy CodePolicy GA-MED-P-366579

Change TypeRevised

Effective DateFebruary 1, 2026

Next Review DateNot specified

Key ActionSubmit pharmacy prior authorization with documentation of age, dermatologist involvement, disease severity, prior treatment failure, safety counseling, and a recent negative tuberculosis test.

SourceLink

POLICY UPDATE CHANGES

Prescriber specialty criteria were revised to allow prescribing by or in consultation with a dermatologist.

The requirement that the prescriber be certified by the Siliq REMS program was removed.

A provider attestation that the member does not have Crohn's disease was added to the initial authorization criteria.

The policy uses a 3% body-surface-area threshold or involvement of sensitive areas to define the required disease severity.

18 yearsMinimum member age

≥3% BSADisease-severity threshold

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentCareSource GeorgiaPolicy GA-MED-P-366579

Siliq (brodalumab) for Plaque Psoriasis

Customize your policy alerts

Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

Get alerted when Policy GA-MED-P-366579 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCareSource Georgia

PolicySiliq (brodalumab) for Plaque Psoriasis

Policy CodePolicy GA-MED-P-366579

Change TypeRevised

Effective DateFebruary 1, 2026

Next Review DateNot specified

SourceLink

POLICY UPDATE CHANGES

Prescriber specialty criteria were revised to allow prescribing by or in consultation with a dermatologist.

The requirement that the prescriber be certified by the Siliq REMS program was removed.

A provider attestation that the member does not have Crohn's disease was added to the initial authorization criteria.

The policy uses a 3% body-surface-area threshold or involvement of sensitive areas to define the required disease severity.

18 yearsMinimum member age

≥3% BSADisease-severity threshold

Coverage Criteria

Continuation Therapy

Covered for reauthorization when the continuation criterion is met:

Reauthorization: Chart notes have been provided showing that the member has shown improvement in signs and symptoms of disease, such as documented improvement in BSA.

If this requirement is met, approval may be extended for an additional 12 months.

Unlisted conditions or indications are excluded from coverage under this policy. Requests for any other indication should be evaluated under the applicable Off-Label policy.

CareSource considers Siliq (brodalumab) not medically necessary for the treatment of conditions that are not listed in this policy.

Authorization and Documentation Requirements

Prior Authorization

Initial Pharmacy Prior Authorization Required

Siliq (brodalumab) requires pharmacy prior authorization. For initial authorization, submit documentation demonstrating that all applicable clinical, treatment-history, safety, and laboratory requirements are met.

Member is 18 years of age or older.
Siliq is prescribed by or in consultation with a dermatologist.
Clinical documentation supports moderate to severe plaque psoriasis.
The member meets the required prior-treatment, safety, counseling, and tuberculosis-testing criteria described below.
When all initial-authorization requirements are met, approval is issued for 4 months.

Billing Rule

Dose and Quantity Limit

Follow the required Siliq loading and maintenance regimen and quantity limit. The loading regimen is followed by every-2-week maintenance dosing.

Loading dose: 210 mg subcutaneously once weekly at weeks 0, 1, and 2.
Maintenance dose: 210 mg subcutaneously every 2 weeks after the loading doses.
Quantity limit: 2 syringes per 28 days after the loading dose.

Documentation Required

Continuation Authorization

For continuation authorization, submit chart notes documenting that the member has improved on therapy. If the continuation requirement is met, Siliq may be approved for an additional 12 months.

Provide chart notes showing improvement in signs and symptoms of disease.
Documentation may include improvement in the member's body surface area (BSA).
Approval duration after successful reauthorization: an additional 12 months.

Step Therapy

Phototherapy or Topical Treatment Trial

Document a qualifying prior phototherapy, photochemotherapy, or topical antipsoriatic treatment trial and failure to respond. The member may also qualify when unable to tolerate the treatment, as applicable.

At least 12 weeks of photochemotherapy, such as psoralen plus ultraviolet A therapy.
At least 12 weeks of phototherapy, such as UVB light therapy or Excimer laser treatments.
At least a 4-week trial of topical antipsoriatic agents, including anthralin, calcipotriene, coal tar, corticosteroids, tazarotene, tacrolimus, or pimecrolimus.
Submit documentation of treatment failure or intolerance.

Step Therapy

Systemic Non-Biologic DMARD Trial

Document that the member has tried and failed to respond to, or is unable to tolerate, a systemic non-biologic DMARD for at least 12 weeks.

Qualifying agents include cyclosporine, methotrexate, and acitretin.
The trial must last at least 12 weeks.
Submit documentation of inadequate response or inability to tolerate the systemic non-biologic DMARD.

Documentation Required

Disease Severity Documentation

Provide clinical documentation establishing moderate to severe plaque psoriasis based on either the required BSA involvement or disease affecting sensitive areas.

Plaque psoriasis affecting at least 3% of body surface area (BSA); or
Disease affecting sensitive areas, such as the hands, feet, face, or genitals.
Include supporting clinical documentation in the authorization submission.

Step Therapy

Prior Treatment History

Document the member's qualifying prior treatment history before requesting initial authorization. The required history includes a qualifying phototherapy, photochemotherapy, or topical trial plus a systemic non-biologic DMARD trial.

Photochemotherapy: at least 12 weeks.
Phototherapy: at least 12 weeks.
Topical antipsoriatic therapy: at least 4 weeks.
Systemic non-biologic DMARD therapy: at least 12 weeks with a qualifying agent.
Document failure to respond or inability to tolerate the applicable treatment.

Documentation Required

Safety and Counseling Records

Submit the required safety attestations and counseling documentation with the member's chart notes. The provider must attest that the member does not have Crohn's disease and document counseling regarding suicidal ideation or behavior risks.

Provider attestation that the member does not have Crohn's disease.
Documented consultation on the risks of suicidal ideation or behavior while taking Siliq.
Negative tuberculosis test obtained within the last 12 months.
Include the safety records and counseling documentation in the authorization submission.

Documentation Required

Reauthorization Response Documentation

For reauthorization, chart notes must demonstrate clinical improvement while receiving Siliq. Documentation should show improvement in disease signs and symptoms, such as a documented improvement in BSA.

Submit current chart notes with the reauthorization request.
Document improvement in signs and symptoms of plaque psoriasis.
Include measurable evidence when available, such as improved BSA.

Denial Risk

Eligibility and Disease-Severity Denial Conditions

Initial authorization may be denied when eligibility, prescriber, disease-severity, or required documentation criteria are not met.

Member is younger than 18 years of age.
Medication is not prescribed by or in consultation with a dermatologist.
Documentation does not establish moderate to severe plaque psoriasis.
Disease involves less than 3% BSA without qualifying sensitive-area involvement.
Required clinical documentation is missing or insufficient.

Denial Risk

Required Prior Treatment Failure

Authorization may be denied when the member lacks the required qualifying prior-treatment failures or when the documented trials are shorter than the required durations.

No documented failure of or inability to tolerate at least one qualifying photochemotherapy, phototherapy, or topical treatment pathway.
Photochemotherapy or phototherapy trial is less than 12 weeks.
Topical antipsoriatic treatment trial is less than 4 weeks.
No documented failure of or inability to tolerate a systemic non-biologic DMARD.
Systemic non-biologic DMARD trial is less than 12 weeks or does not involve a qualifying agent.

Denial Risk

Safety Documentation Denial Conditions

Authorization may be denied when required safety attestations, counseling, or laboratory records are absent or unfavorable.

Provider does not attest that the member does not have Crohn's disease.
Documentation of counseling regarding suicidal ideation or behavior risks is missing.
Negative tuberculosis testing within the previous 12 months is not documented.
Required safety records are incomplete.

Denial Risk

Unlisted Indications

Siliq is not medically necessary for conditions or indications not listed in this policy. For any other indication, refer to the applicable Off-Label policy.

Unlisted indications are not medically necessary under this policy.
Use the applicable Off-Label policy for other indications.

Clinical Background

Siliq (brodalumab) is a human interleukin-17 receptor A antagonist indicated for adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy and have failed or lost response to other systemic therapies. Plaque psoriasis is an immune-mediated inflammatory disease characterized by recurrent flares and relapses, with plaques commonly affecting the scalp, trunk, arms, and legs.

Policy Definitions

Siliq (brodalumab)

MedicationSiliq (brodalumab)

Therapeutic classHuman interleukin-17 receptor A antagonist (IL-17RA antagonist)

Policy useTreatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy and have failed or lost response to other systemic therapies.

BSA

DefinitionBody surface area affected by psoriasis.

Policy thresholdAt least 3% BSA is required to establish moderate to severe plaque psoriasis.

Exception