Siliq (brodalumab) prior authorization for plaque psoriasis
This document is a prior authorization form governing coverage requirements for Siliq (brodalumab) for adults with moderate-to-severe chronic plaque psoriasis. It applies to providers submitting requests for Colorado Rocky Mountain Health Plans beneficiaries.
No material clinical or coverage changes in this revision.
Coverage Criteria for Siliq (brodalumab)
Initial Therapy — Covered when ALL of the following are met
Covered when ALL of the following are met:
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When a beneficiary is currently receiving another injectable biologic immunomodulator, the form explicitly asks whether the beneficiary is not on another injectable biologic immunomodulator. If the answer is negative or documentation is absent, the request may be excluded from consideration. Providers should document the current biologic therapy and rationale for switching (e.g., lack of efficacy, intolerance, or contraindication) on the prior authorization form and include supporting clinical notes to avoid exclusion for concurrent biologic use.
The form identifies several implicit coverage-failure conditions: lack of documentation that the beneficiary is ≥ 18 years old, absence of recorded BSA ≥ 3% or qualifying critical-site involvement, missing evidence of prior treatment failure (phototherapy and one systemic agent plus trial/failure of Cosentyx, Enbrel, or Humira unless contraindicated), no documented screening for latent tuberculosis, missing Hepatitis B surface antigen and core antibody test results, or failure to confirm enrollment in the Siliq REMS program. Any of these undocumented items may render the request non-covered per the form requirements.
Coding and Clinical Thresholds
Provider Actions and Requirements
Prior Authorization Required
Prior authorization is required. Providers must complete the prior authorization form in full, including beneficiary and prescriber information, drug name/strength/quantity/length of therapy, signatures, and requester contact details before submission.
- Complete beneficiary information (name, ID number, DOB, gender).
- Include prescriber NPI and requester contact name and phone number.
- Specify drug name, strength, quantity per 30 days, and length of therapy.
- Include prescriber signature and date.
Required Prior Therapy
Required prior therapy must be documented. Member must have failed or been intolerant to phototherapy and at least one systemic agent (acitretin/Soriatane, methotrexate, or cyclosporine). Additionally, the member must have had a trial and failure of Cosentyx, Enbrel, or Humira, or a documented clinical reason they cannot try these agents.
- Document failure or intolerance to phototherapy and ONE of: Soriatane (acitretin), methotrexate, or cyclosporine.
- Document trial and failure of Cosentyx, Enbrel, or Humira, or provide clinical rationale for not using them.
Required Documentation
Providers must include all required documentation with the PA request. Incomplete documentation may delay processing or result in denial.
- Beneficiary ID and demographics (name, DOB, gender).
- Prescriber NPI and contact information (phone, requester name/extension).
- Drug name, strength, quantity per 30 days, and requested length of therapy.
- Signed prescription and prescriber signature/date on the form.
- Clinical documentation supporting diagnosis (moderate-to-severe chronic plaque psoriasis), BSA% or description of involvement, prior treatment history, TB and Hep B testing results, and REMS enrollment when required.
Potential Denial Triggers
Potential denial triggers — requests missing key clinical or administrative information may be denied.
- Missing beneficiary age or documentation that member is ≥18 years old.
- Missing body surface area (BSA) documentation or insufficient description of disease extent.
- Lack of documentation of prior treatment failures or intolerance (phototherapy, systemic agents, specified biologics).
- No documentation of TB screening or Hepatitis B testing when required.
- Failure to confirm REMS registration (when applicable) or missing prescriber signature/contact information.
- Incomplete drug information (name, strength, quantity, length of therapy).
Background
This prior authorization form supports requests for Siliq (brodalumab) for adults with moderate-to-severe chronic plaque psoriasis. It collects clinical eligibility elements used to determine medical necessity, including confirmed diagnosis, age ≥ 18 years, disease extent (either BSA ≥ 3% or involvement of palms/soles/head-neck/genitalia causing disruption of daily activities or employment), prior treatment history (failure or intolerance to phototherapy and one systemic agent, plus trial/failure of Cosentyx, Enbrel, or Humira unless clinically contraindicated), screening for latent tuberculosis and Hepatitis B (SAG and Core Ab), and confirmation that providers, pharmacies, and beneficiaries are registered in the Siliq REMS program. The prescriber’s signature and date are required to attest to the accuracy of the information.
Definitions
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