CurrentCignaPolicy N/A

Siliq (brodalumab) Drug Quantity Management Policy

Defines quantity limits, exceptions, and authorization rules for Siliq (brodalumab) supplied to Cigna-administered health benefit plans; affects providers and pharmacies submitting claims for Siliq.

Policy Summary

PayerCigna

PolicySiliq (brodalumab) Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeClarification — one-time override durationroutine review

Effective DateN/A

Next Review DateN/A

Key ActionVerify no Siliq claims in the past 130 days to request a one-time initiation override.

SourceLink

POLICY UPDATE CHANGES

The Policy Statement was updated to clarify that 'One-time' overrides are provided for 30 days in duration.

Annual revisions with review dates noted for 01/04/2024, 02/10/2025, and 02/05/2026; most recent notes indicate no criteria changes except the Policy Statement clarification.

420 mgRetail max per 28 days

1,260 mgHome delivery max per 84 days

840 mgOne-time retail override

1,680 mgOne-time home delivery override

Coverage Criteria

Policy Summary

PayerCigna

PolicySiliq (brodalumab) Drug Quantity Management Policy

Policy CodePolicy N/A

Change TypeClarification — one-time override durationroutine review

Effective DateN/A

Next Review DateN/A

Key ActionVerify no Siliq claims in the past 130 days to request a one-time initiation override.

SourceLink

On This Page

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Initiation/Induction Override

Exceptions to the quantity limits listed are covered as medically necessary when the following are met:

Initiation/induction override: Patient is initiating treatment or requires additional induction dosing, as verified by absence of claims for Siliq in the past 130 daysno claims for Siliq in the past 130 days

If met, approve a one-time override: retail 840 mg (4 syringes) or home delivery 1,680 mg (8 syringes). One-time approvals are provided for 30 days in duration.

Any exception other than those specifically listed is considered not medically necessary.

Requests exceeding the quantity limits without meeting the listed exception criteria are considered not medically necessary.

Provider Actions and Operational Notes

Denial Risk

Quantity limits and one-time override

Quantity limits apply to Siliq (brodalumab) as follows: Retail maximum = 420 mg per 28 days (2 syringes); Home Delivery maximum = 1,260 mg per 84 days (6 syringes). Claims for quantities exceeding these limits will be subject to the Drug Quantity Management rule and may be denied unless an exception is approved per the policy criteria.

Retail maximum: 420 mg per 28 days (2 syringes)
Home Delivery maximum: 1,260 mg per 84 days (6 syringes)

Prior Authorization

Quantity limits and one-time override — initiation rules

A one-time override for initiation or additional induction dosing is approved when the patient has no claims for Siliq in the past 130 days. For initiation, approve a one-time override of 840 mg (4 syringes) at retail or 1,680 mg (8 syringes) at home delivery. The home delivery override supports initiation dosing at Week 0, Week 1, and Week 2, followed by 210 mg every 2 weeks at Weeks 4, 6, 8, 10, and 12. All one-time approvals are provided for a 30-day duration.

One-time override criteria: no Siliq claims in past 130 days
One-time override amounts: 840 mg (4 syringes) retail; 1,680 mg (8 syringes) home delivery
One-time approval duration: 30 days
Home delivery initiation schedule: Week 0, Week 1, Week 2, then 210 mg every 2 weeks at Weeks 4, 6, 8, 10, 12

Note

Dose management

Policy manages potential premature dose escalation. If the Drug Quantity Management rule is not met at point of service, coverage will be determined according to the policy criteria. Providers should anticipate dose-management review and ensure documentation supports the need for dose escalation (e.g., treatment initiation timing, prior dosing history).

If Drug Quantity Management rule not met at point of service, adjudication follows policy criteria
Providers should submit documentation demonstrating absence of prior Siliq claims or clinical rationale for escalation

Billing Rule

Quantity limit denial risk and billing expectations

Claims for quantities exceeding the stated retail or home delivery maximums will be subject to the Drug Quantity Management rule; exceptions are limited to the specified one-time initiation override or other criteria-based approvals detailed in the policy. Providers should follow the applicable benefit plan and submission requirements when requesting overrides or exceptions.

Excess quantity claims will be reviewed under Drug Quantity Management rules
Exceptions allowed only when criteria are met (e.g., initiation override)
Follow applicable benefit plan billing and documentation requirements when requesting exceptions

Background

Siliq (brodalumab) is indicated for adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy and who have failed or lost response to other systemic therapies. The recommended induction schedule is 210 mg subcutaneously at Weeks 0, 1, and 2, then 210 mg every 2 weeks, which may require additional syringes beyond routine quantity limits to complete the induction course.

For quantity management, Siliq is supplied as a 210 mg/1.5 mL prefilled syringe. Standard quantity limits are 420 mg per 28 days (retail) and 1,260 mg per 84 days (home delivery). A one-time initiation/induction override may be approved when criteria are met to allow additional syringes to cover the induction schedule.

Initial / Induction Therapy Criteria

Initial/Induction Dosing

Initial/induction dosing allowance when no recent claims for Siliq exist.

Initial therapy allowance: Absence of Siliq claims in past 130 days130 days

Approve one-time override to permit induction dosing: retail 840 mg (4 syringes) or home delivery 1,680 mg (8 syringes) to cover the Weeks 0, 1, 2 induction schedule and subsequent dosing through Week 12. One-time approvals are provided for 30 days in duration.

Induction dosing schedule (clinical context): Recommended dosing: 210 mg subcutaneously at Weeks 0, 1, and 2, then 210 mg every 2 weeks

Quantity Limits and Overrides

Retail quantity limit

Drug formulationSiliq (brodalumab) 210 mg/1.5 mL prefilled syringe

Retail maximum420 mg per 28 days (2 syringes)

Unit detail210 mg per syringe; retail limit equals 2 syringes per 28 days

Home delivery quantity limit

Drug formulationSiliq (brodalumab) 210 mg/1.5 mL prefilled syringe

Home delivery maximum1,260 mg per 84 days (6 syringes)

Unit detail210 mg per syringe; home delivery limit equals 6 syringes per 84 days

Retail one-time override (initiation)

One-time retail override840 mg (4 syringes) — approved as a one-time override for initiation when no Siliq claims in past 130 days; duration 30 days

PurposeCovers induction dosing Weeks 0,1,2 and subsequent dosing through Week 12

Relation to retail limitOverrides the standard retail maximum (420 mg/28 days) for initiation

Home delivery one-time override (initiation)

One-time home delivery override1,680 mg (8 syringes) — approved as a one-time override for initiation when no Siliq claims in past 130 days; duration 30 days

PurposeAllows initiation dosing at Weeks 0,1,2 and 210 mg every 2 weeks at Weeks 4–12 as specified in policy note

Relation to home delivery limitOverrides the standard home delivery maximum (1,260 mg/84 days) for initiation

OpenPayer

Siliq (brodalumab) Drug Quantity Management Policy

Coverage Criteria

Coding / Claims Indicators

Provider Actions and Operational Notes

Background

Definitions

Initial / Induction Therapy Criteria

Quantity Limits and Overrides

Site of Care