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Colorado Rocky Mountain Health Plans Taltz Prior Auth | OpenPayer

ModifiedColorado Rocky Mountain Health PlansPolicy 2025 P 3073-19

Taltz® (ixekizumab) - Step Therapy - UnitedHealthcare Commercial Plansopen_in_new

Step therapy program defining required prior trials of preferred alternative products before coverage of Taltz (ixekizumab) for plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis for UnitedHealthcare Commercial Plans (effective 2025-06-01). Infused medications are not part of criteria; Taltz is excluded from coverage for the majority of benefits unless criteria met.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTaltz® (ixekizumab) - Step Therapy - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2025 P 3073-19

Change TypeModified (material updates & approvals through 4/2025)

Effective DateJun 1, 2025

Next Review Date

Key ActionPrior authorization required demonstrating documented trials (drug, date, duration) of required preferred products per indication; authorization issued for 12 months when criteria met.

SourceLink

POLICY UPDATE CHANGES

Effective date set to 6/1/2025 and program number recorded.

Removed examples for adalimumab in step therapy and changed Stelara wording to 'One of the preferred ustekinumab productsc'.

Added Sotyktu as step therapy agent for plaque psoriasis and moved Cosentyx to preferred step agent.

Added that Taltz is excluded from coverage for the majority of benefits.

Annual reviews with no change to clinical intent recorded (multiple dates e.g., 11/2021, 4/2024).

4Indications with explicit step criteria (PsO, PsA, AS, nr-axSpA)

3+Required prior preferred trials for most indications

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Coverage Summary

Plaque Psoriasis - Initial Approval

Covered when ALL of the following are met:

ALL of the following

ONE of
- - One of the preferred adalimumab products
  - Cimzia (certolizumab)
  - Cosentyx (secukinumab)
  - Enbrel (etanercept)
  - Skyrizi (risankizumab)
  - Sotyktu (deucravacitinib)
  - One of the preferred ustekinumab products
  - Tremfya (guselkumab)
PEDIATRIC BRANCH
- Pediatric pathway
  - Patient is less than 18 years of age
  - History of failure, contraindication, or intolerance to Cosentyx (secukinumab), Enbrel (etanercept), or one of the preferred ustekinumab products (document date and duration of trial)

ALL of the following

Authorization duration: 12 months
Operational

Psoriatic Arthritis - Initial Approval

Covered when ALL of the following are met:

ALL of the following

- One of the preferred adalimumab products
- Cimzia (certolizumab)
- Cosentyx (secukinumab)
- Enbrel (etanercept)
- Simponi (golimumab)

Ankylosing Spondylitis - Initial Approval

Covered when ALL of the following are met:

ALL of the following

- One of the preferred adalimumab products
- Cimzia (certolizumab)
- Cosentyx (secukinumab)
- Enbrel (etanercept)
- Simponi (golimumab)

Non-radiographic Axial Spondyloarthritis - Initial Approval

Covered when ALL of the following are met:

ALL of the following

- Cimzia (certolizumab)
- Cosentyx (secukinumab)
- Rinvoq (upadacitinib)
Authorization duration: 12 months
Operational

Other Diagnoses

Covered when ALL of the following are met:

ALL of the following

Taltz will be approved for other diagnoses when clinically appropriate and consistent with state mandates, federal requirements, and the member's specific benefit plan. Document clinical rationale, relevant prior therapy, and supporting diagnostic information.
Authorization duration: 12 months
Operational
Exclusion note: Taltz is excluded from coverage for the majority of benefits; approval may be limited by plan-specific exclusions, medical necessity rules, supply limits, and notification requirements.

Provider Actions & Billing Impact

Prior Authorization

Step therapy prior authorization required

Prior authorization is required. Providers must demonstrate documented trials of the required preferred products for the relevant indication (documenting drug name, date, and duration). When the criteria are met, authorization will be issued for 12 months.

Documentation Required

Document trials

Providers must document each prior trial showing failure, contraindication, or intolerance. Documentation must include the drug name, the date of the trial, and the duration of the trial.

Drug name
Date of trial
Duration of trial

Applicable Codes

No specific billing codes provided in documentmixed

No codes listed

Definitions & Background

Step therapy is used to encourage use of lower-cost preferred alternatives prior to providing coverage for Taltz. The program requires members to try preferred products appropriate to the indication before Taltz will be authorized. Infused medications for the referenced conditions are not part of the step therapy criteria.

Preferred biologic and targeted synthetic DMARD alternatives are listed by indication in the criteria and include agents such as adalimumab products, Cimzia (certolizumab), Cosentyx (secukinumab), Enbrel (etanercept), Skyrizi (risankizumab), Sotyktu (deucravacitinib), ustekinumab products, Tremfya (guselkumab), Simponi (golimumab), Orencia (abatacept), Xeljanz (tofacitinib), and Rinvoq (upadacitinib) as applicable to the specific diagnosis.

The program has been maintained and reviewed by the Pharmacy & Therapeutics (P&T) committee with approval entries since 2016 and multiple subsequent reviews through 4/2025.

History of failure, contraindication, or intolerance: Documented trial of the medication including drug name, date, and duration showing lack of efficacy, contraindication, or intolerance.

One of the preferred adalimumab products / One of the preferred ustekinumab products: For the current list of preferred product examples reference drug coverage tools.

Clinical Evidence

This policy document does not include specific clinical trial evidence. Preferred product lists and examples are referenced via external drug coverage tools as noted in the criteria.

Revision History

2025-06-01effective_dateLatest

Program effective date set to 6/1/2025 following P&T approvals through 4/2025 (Program 2025 P 3073-19).

2025-04policy_revisionLatest

April 2025 revision: removed adalimumab examples in step therapy, changed Stelara wording to 'One of the preferred ustekinumab products' and added a footnote to reference drug coverage tools for preferred product lists.