CurrentCignaPolicy N/A

Inflammatory Conditions - Taltz Drug Quantity Management Policy - Per Days

Defines drug quantity limits and medically necessary exceptions for Taltz (ixekizumab) formulations for Cigna-administered benefit plans; affects prescribing providers and pharmacy benefit adjudication.

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Taltz Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeQuantity limits added; induction override clarified

Effective DateN/A

Next Review DateN/A

Key ActionApprove one-time induction overrides for 80 mg/mL formulations when initiation or additional induction dosing is required, per the specified retail or home delivery limits.

SourceLink

POLICY UPDATE CHANGES

New quantity limits were added for Taltz 20 mg/0.25 mL and 40 mg/0.5 mL prefilled syringes.

Override criteria for 80 mg/mL preparations were clarified to include patients who require additional induction dosing (not only initiating therapy).

Policy statement updated to note that 'One-time' approvals are provided for 30 days in duration.

0.25 mLRetail max 20 mg/0.25 mL

0.75 mLHome delivery max 20 mg/0.25 mL

0.5 mLRetail max 40 mg/0.5 mL

1.5 mLHome delivery max 40 mg/0.5 mL

1 mLRetail max 80 mg/mL

3 mLHome delivery max 80 mg/mL

Coverage Criteria

Quantity limit exceptions and induction/initial dosing overrides

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

Taltz 20 mg/0.25 mL: No overrides recommended; retail maximum 0.25 mL per 28 days (1 syringe); home delivery maximum 0.75 mL per 84 days (3 syringes).

Any other exception is considered not medically necessary.

Taltz 40 mg/0.5 mL: No overrides recommended; retail maximum 0.5 mL per 28 days (1 syringe); home delivery maximum 1.5 mL per 84 days (3 syringes).

Any other exception is considered not medically necessary.

Taltz 80 mg/mL initiation or induction - adults for psoriatic arthritis or ankylosing spondylitis: Patient ≥ 18 years initiating treatment or requiring additional induction dosing for psoriatic arthritis or ankylosing spondylitis, verified by absence of claims for Taltz in the past 130 days.

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Taltz Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeQuantity limits added; induction override clarified

Effective DateN/A

Next Review DateN/A

Key ActionApprove one-time induction overrides for 80 mg/mL formulations when initiation or additional induction dosing is required, per the specified retail or home delivery limits.

SourceLink

On This Page

Initial/Induction Therapy Criteria

Induction/Initiation overrides

Initial/induction dosing overrides for 80 mg/mL formulations

Adult psoriatic arthritis or ankylosing spondylitis initiation: Patient >=18 years and no claims for Taltz in the past 130 days; approve one-time override: retail 2 mL (2 syringes/2 auto-injectors) or home delivery 4 mL (4 syringes/4 auto-injectors).absence of claims for Taltz in the past 130 days

Adult plaque psoriasis initiation: Patient >=18 years and no claims for Taltz in the past 130 days; approve one-time override: retail 4 mL (4 syringes/4 auto-injectors) followed by 2 mL per 28 days for 84 days at retail OR one-time home delivery 8 mL (8 syringes/8 auto-injectors).absence of claims for Taltz in the past 130 days

Completing induction for adult plaque psoriasis: Patient >=18 years currently completing induction dosing for plaque psoriasis; approve 2 mL per 28 days for 84 days at retail or one-time home delivery override for 8 mL.

Pediatric (>50 kg) plaque psoriasis initiation: Patient <18 years and weight >50 kg and no claims for Taltz in the past 130 days; approve one-time override: retail 2 mL (2 syringes/2 auto-injectors) or home delivery 4 mL (4 syringes/4 auto-injectors).weight >50 kg and absence of claims for Taltz in the past 130 days

Quantity Limits by Formulation and Setting

Taltz 20 mg/0.25 mL prefilled syringe — Retail maximum

Retail maximum quantity0.25 mL per 28 days (1 syringe)

Unit20 mg/0.25 mL prefilled syringe

Coverage noteNo overrides recommended for this strength; exceptions must meet specified criteria to be medically necessary.

Taltz 20 mg/0.25 mL prefilled syringe — Home delivery maximum

Home delivery maximum quantity0.75 mL per 84 days (3 syringes)

Unit20 mg/0.25 mL prefilled syringe (home delivery)

Coverage noteAny request exceeding home delivery limits is not medically necessary unless exception criteria are met.

Taltz 40 mg/0.5 mL prefilled syringe — Retail maximum

Retail maximum quantity0.5 mL per 28 days (1 syringe)

Unit40 mg/0.5 mL prefilled syringe

Coverage noteNo overrides recommended for this strength; exceptions must meet specified criteria to be medically necessary.

Taltz 40 mg/0.5 mL prefilled syringe — Home delivery maximum

Home delivery maximum quantity1.5 mL per 84 days (3 syringes)

Unit40 mg/0.5 mL prefilled syringe (home delivery)

Coverage noteAny request exceeding home delivery limits is not medically necessary unless exception criteria are met.

Taltz 80 mg/mL prefilled syringe — Retail maximum

Retail maximum quantity1 mL per 28 days (1 syringe)

Unit80 mg/mL prefilled syringe

NoteInitiation/induction overrides exist for 80 mg/mL formulations per criteria; otherwise quantity limits apply.

Taltz 80 mg/mL prefilled syringe — Home delivery maximum

Home delivery maximum quantity3 mL per 84 days (3 syringes)

Unit80 mg/mL prefilled syringe (home delivery)

NoteOne-time or time-limited induction/ initiation overrides may permit larger home delivery quantities as specified in criteria.

Taltz 80 mg/mL auto-injector — Retail maximum

Retail maximum quantity1 mL per 28 days (1 autoinjector)

Unit80 mg/mL auto-injector

NoteInitiation/induction overrides for 80 mg/mL auto-injectors are described in the policy and may allow one-time larger retail quantities when criteria are met.

Taltz 80 mg/mL auto-injector — Home delivery maximum

Home delivery maximum quantity3 mL per 84 days (3 autoinjectors)

Unit80 mg/mL auto-injector (home delivery)

NoteOne-time home delivery overrides for induction may permit up to the specified larger quantities when criteria are met.

Site of Care / Dispensing Setting

Denial Risk

Overrides not recommended

Overrides not recommended. Retail dispensing and home delivery have different maximum quantities and one-time override allowances; ensure requests meet the specific exception criteria before submitting. For Taltz (ixekizumab): retail maximums are per 28 days (typically 1 syringe/autoinjector depending on strength) while home delivery maximums are per 84 days (typically 3 syringes/autoinjectors). One-time overrides allowed only when ALL applicable exception criteria are met (examples below).

Retail maximum quantities are measured per 28 days; home delivery maximum quantities are measured per 84 days.
Examples of one-time overrides for 80 mg/mL prefilled syringes/auto-injectors (must meet criteria described in source):
• Adults (≥18) initiating psoriatic arthritis or ankylosing spondylitis: one-time override — Retail: 2 mL (2 syringes/auto-injectors); Home delivery: 4 mL (4 syringes/auto-injectors).
• Adults initiating plaque psoriasis or needing induction dosing: one-time override — Retail: 4 mL (4 syringes/auto-injectors) then 2 mL per 28 days for 84 days; Home delivery: one-time override 8 mL (8 syringes/auto-injectors).
• Adults currently completing induction for plaque psoriasis: approve 2 mL per 28 days for 84 days at retail or one-time home delivery override of 8 mL.
• Pediatrics (<18) weighing >50 kg initiating plaque psoriasis: one-time override — Retail: 2 mL; Home delivery: 4 mL.

Provider Actions and Prior Authorization

Prior Authorization

Quantity limits apply by strength and setting; overrides require meeting induction/initiation criteria

Quantity limits are applied by product strength and by dispensing setting (retail vs home delivery). Overrides are permitted only when the specific induction/initiating criteria are met and are granted as one-time or time-limited approvals per the policy.

Limits are set per strength (20 mg/0.25 mL, 40 mg/0.5 mL, 80 mg/mL) and per setting (retail per 28 days; home delivery per 84 days).
When induction/initiation criteria for 80 mg/mL formulations are met (e.g., absence of Taltz claims in past 130 days or completing induction), approve the one-time or time-limited override amounts listed in the criteria.
Any request exceeding stated limits without meeting the exception criteria is considered not medically necessary.

Step Therapy

No overrides recommended for 20 mg and 40 mg prefilled syringes

For the 20 mg/0.25 mL and 40 mg/0.5 mL prefilled syringes, the policy states that no overrides are recommended; requests exceeding the listed quantity limits for these strengths are considered not medically necessary unless criteria explicitly allow otherwise.

Taltz 20 mg/0.25 mL prefilled syringes — No overrides recommended.
Taltz 40 mg/0.5 mL prefilled syringes — No overrides recommended.

Documentation Required

Approval durations: 1 year standard; 'One-time' = 30 days

Standard approvals are issued for 1 year unless otherwise noted; 'One-time' overrides/approvals specified in the induction criteria are provided for 30 days in duration.

General approvals = 1 year duration unless noted.
'One-time' approvals = 30 days in duration.

Denial Risk

Coverage determined by criteria when Drug Quantity Management rule not met

If the Drug Quantity Management rule is not met at point of service, coverage determination will default to the written criteria. Quantities outside the listed limits are considered not medically necessary unless an exception meeting the specified criteria is provided and approved.

When rule not met at point of service, adjudication follows the policy criteria.
Requests exceeding limits without meeting exception criteria are not medically necessary.

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