CurrentCignaPolicy IP0688

Taltz Prior Authorization Policy

Defines Cigna's prior authorization requirements, medical necessity criteria, and coverage limitations for Taltz (ixekizumab) for inflammatory conditions across enrolled members; affects prescribers, reviewers, and payers administering Cigna benefit plans.

Policy Summary

PayerCigna

PolicyTaltz Prior Authorization Policy

Policy CodePolicy IP0688

Change TypeNo material change

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization and document specialty consultation, age, prior therapy trials or contraindications, and objective baseline/response measures as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4FDA-approved indications listed

PA requiredCoverage stance

6 moInitial approval duration

07/01/2025Policy effective date

Coverage and Medical Necessity Criteria

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Taltz (ixekizumab) is covered only for its FDA‑approved indications as detailed in this policy. Use of Taltz for any other indication is considered not medically necessary. This exclusion specifically includes situations where Taltz would be used outside the FDA‑approved disease groups described in the coverage criteria.

Concurrent therapy with another biologic or a targeted synthetic oral small molecule for an inflammatory condition is not medically necessary. Combination use is discouraged because of higher rates of adverse events and lack of controlled data demonstrating additive benefit. Note that this exclusion does not apply to combination with methotrexate.

Billing Codes and Lab Criteria

inv-09: Elevated C-reactive protein — lab criterion (greater than upper limit of normal)

CriterionC-reactive protein (CRP) elevated beyond the upper limit of normal for the reporting laboratory

ContextRequired as one of the objective signs of inflammation for initial therapy approval in non-radiographic axial spondyloarthritis (nr-axSpA)

Use in decision-makingMeets the policy requirement for objective inflammation when recorded as greater than the laboratory's ULN; may be used alone or with MRI sacroiliitis to satisfy inflammation criterion

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required for benefit coverage of Taltz. All approvals are for the duration noted in the policy (months convert to 30-day increments where applicable). Initial approvals require the medication to be prescribed by or in consultation with a physician who specializes in the condition being treated (e.g., rheumatologist for AS, dermatologist for psoriasis). This product also requires use of preferred products per the Inflammatory Conditions Preferred Specialty Management Policy (PSM002) before approval; refer to PSM002 for step requirements and exceptions.

Prior authorization required for Taltz (ixekizumab).
Initial approval: prescribed by or in consultation with appropriate specialist (rheumatologist, dermatologist, as applicable).
Approval durations specified in the policy (e.g., 6 months initial for many adult indications; 3 months initial for pediatric plaque psoriasis; continuation approvals commonly 1 year when established).
Use preferred products per PSM002 before approval; see PSM002 for specific step-therapy rules and exceptions.

Note

Appendix: Alternative Biologic and Oral Therapies

The Appendix lists alternative biologic and targeted therapies by mechanism of action and example indications (e.g., other IL-17A inhibitors, IL-23 inhibitors, TNF inhibitors, JAK inhibitors, PDE4 inhibitors, S1P modulators, oral targeted small molecules). Providers should refer to the Appendix for examples of agents and their mechanisms/indications when considering prior therapy or exceptions.

Appendix enumerates multiple biologics and oral therapies as examples (IL-17 inhibitors including Taltz, Cosentyx, brodalumab; IL-23 inhibitors like Skyrizi, Tremfya; TNF inhibitors such as adalimumab, etanercept; JAK inhibitors and others).
Appendix entries include mechanism of action and example indications; not an exhaustive list—refer to prescribing information for full indications.

Documentation Required

Appendix Abbreviations and Prescribing Information Note

The Appendix provides abbreviations used in the policy and a note to refer to the prescribing information for each agent. It is not a complete checklist of documentation; providers should include relevant clinical measures, prior therapy history, specialist input, and objective assessments referenced in the clinical criteria when submitting authorization requests.

Appendix abbreviations: e.g., SC, IV, TNF, AS, PsO, PsA, RA, UC, nr-axSpA, PJIA, IL, PDE4, JAK, TYK2, AD, AA.
Refer to the prescribing information for FDA-approved indications and further agent-specific details.
No explicit documentation checklist is provided in the Appendix; include clinical objective measures and prior therapy details per the coverage criteria.

Denial Risk

Denial Conditions / Claims

No explicit denial triggers are listed in the Appendix excerpt beyond the general policy statement that claims submitted without covered diagnosis/procedure codes or not meeting coverage criteria will be denied as not covered. Providers should ensure authorization requests include covered codes and meet all stated clinical criteria; failure to do so may result in denial.

Claims submitted without covered diagnosis/procedure codes or not meeting Coverage Policy criteria will be denied as not covered.
The Appendix lists agents and example indications but does not specify explicit prior authorization denial triggers beyond the policy criteria and coding requirements.

Background

Taltz (ixekizumab) is an interleukin‑17A (IL‑17A) antagonist indicated for several immune‑mediated inflammatory conditions, including ankylosing spondylitis (AS), non‑radiographic axial spondyloarthritis (nr‑axSpA), plaque psoriasis (PsO), and psoriatic arthritis (PsA). Clinical trial programs supporting nr‑axSpA included requirements for objective signs of inflammation such as elevated C‑reactive protein or MRI evidence of sacroiliitis. Refer to the FDA‑approved prescribing information and this policy’s coverage criteria for indication‑specific age limits, prescribing specialist requirements, and approval durations.

Definitions and Abbreviations

inv-19: Objective signs of inflammation (for nr-axSpA) — key clinical definition items

Definition: Objective signs of inflammationDefined as at least one of: elevated C-reactive protein beyond the laboratory upper limit of normal OR sacroiliitis on magnetic resonance imaging (MRI)

Context — nr-axSpA requirementPivotal nr-axSpA trials required objective signs of inflammation (elevated CRP and/or MRI sacroiliitis) for enrollment; policy mirrors this requirement for initial therapy approvals

Prescriber requirementInitial therapy for nr-axSpA must be prescribed by or in consultation with a rheumatologist when objective inflammation is present

inv-20: Abbreviations from appendix — PsO, PsA, AS, nr-axSpA, CD, etc.

PsOPlaque psoriasis

PsAPsoriatic arthritis

ASAnkylosing spondylitis

nr-axSpANon-radiographic axial spondyloarthritis

CD / UCCrohn's disease / Ulcerative colitis

IL / JAK / PDE4 / S1PInterleukin / Janus kinase / Phosphodiesterase 4 / Sphingosine 1 phosphate (mechanism-class abbreviations referenced in appendix)