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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsHMSA SILIQ Plaque Psoriasis Coverage | OpenPayer
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    CurrentHawaii Medical Service Association (HMSA)Policy N/A

    SILIQ (brodalumab) Coverage Criteria for Plaque Psoriasis

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    This policy governs HMSA coverage and prior authorization for SILIQ (brodalumab) in adult members with moderate to severe plaque psoriasis. Coverage requires applicable clinical criteria, prescriber requirements, safety screening, and absence of exclusions.

    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicySILIQ (brodalumab) coverage for moderate to severe plaque psoriasis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 27, 2025
    Last ReviewJun 1, 2025
    Next Review DateN/A
    Key ActionPrecertification is required for SILIQ; providers should use the HMSA medical policy website fax form.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsInitial and reauthorization approval period

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≥10% BSA
    Body-surface-area threshold supporting coverage
    ≥3% BSAAlternative body-surface-area threshold
    DermatologistRequired prescriber specialty
    Within 12 monthsNegative TB test timing when applicable

    Coverage Criteria

    Initial therapy for plaque psoriasis

    Covered when all applicable member and indication requirements are met and at least one qualifying pathway applies.

    Initial approval

    • Qualifying pathways

      • Prior advanced therapy: The member has previously received a biologic or targeted synthetic drug indicated for moderate to severe plaque psoriasisPrior biologic or targeted synthetic drug

        Examples include Sotyktu and Otezla.

      • Disease extent or severity pathway

        • Crucial body areas are affectedHands, feet, face, neck, scalp, genitals/groin, or intertriginous areas
        • At least 10% BSA: At least 10% of body surface area is affected≥10% BSA

        • At least 3% BSA with additional criterion

          • Prior treatment failure or intolerance: The member has had an inadequate response or intolerance to phototherapy or pharmacologic treatment with methotrexate, cyclosporine, or acitretin
          • Clinical reason to avoid treatment: The member has a clinical reason to avoid pharmacologic treatment with methotrexate, cyclosporine, and acitretin

            Examples are listed in the policy appendix.

    Continuation and reauthorization

    Continuation and reauthorization require the applicable initial criteria or documented prior authorization and clinical response.

    Continuation pathways

    • No previous authorization: The member meets all initial approval criteria, including new members and members currently receiving treatment without prior authorizationInitial criteria satisfied

    • Reauthorization

      • Response measure

        • Clinical response evidence: Reduction in affected body surface area from baseline or improvement in signs and symptoms from baselineReduced BSA or improved itching, redness, flaking, scaling, burning, cracking, or pain

    Do not administer SILIQ to a member with active tuberculosis (TB) infection. If TB screening is positive, further testing must confirm that active disease is absent, such as a chest X-ray. When latent TB is identified, treatment must be started before SILIQ is initiated.

    SILIQ must not be used concomitantly with another biologic drug or targeted synthetic drug for the same indication.

    Clinical Thresholds

    Affected body surface area
    ThresholdAt least 10% of body surface area (BSA) must be affected.
    ConditionApplies to adult members with moderate to severe plaque psoriasis.
    Authorization periodAuthorization may be granted for 12 months when the applicable coverage criteria are met.
    Alternative 3% BSA pathway
    BSA thresholdAt least 3% of body surface area (BSA) must be affected.
    Treatment response or intoleranceThe member must have an inadequate response or intolerance to phototherapy, methotrexate, cyclosporine, or acitretin.
    Clinical avoidance pathway

    Provider Requirements and Approval Risks

    Prior Authorization

    Precertification Required

    Precertification is required for SILIQ. Direct providers to the HMSA medical policy website for the required fax form.

    Documentation Required

    Dermatology Involvement Required

    SILIQ must be prescribed by or used in consultation with a dermatologist.

    Step Therapy

    Prior Biologic or Targeted Synthetic Therapy

    For an adult member with moderate to severe plaque psoriasis, document previous treatment with a biologic or targeted synthetic drug indicated for the condition, such as Sotyktu or Otezla.

    Policy Background

    SILIQ (brodalumab) is covered for adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy and have failed to respond or lost response to other systemic therapies. Coverage is determined by disease extent, involvement of crucial body areas, prior treatment history, treatment intolerance or contraindications, and documented clinical response.

    Initial Therapy

    Initial plaque psoriasis therapy

    Initial authorization of 12 months may be granted when the adult member has moderate to severe plaque psoriasis and meets at least one qualifying pathway.

    Initial plaque psoriasis approval

    • Qualifying pathway

      • Prior advanced therapy: The member has previously received a biologic or targeted synthetic drug indicated for moderate to severe plaque psoriasis

      • Disease extent pathway

        • Crucial body areas are affectedHands, feet, face, neck, scalp, genitals/groin, or intertriginous areas

    Continuation and Reauthorization

    Reauthorization

    Continuation requires either satisfaction of the initial approval criteria or prior HMSA/CVS authorization with documented clinical response.

    Continuation approval

    • Initial criteria pathway: The member meets the initial approval criteria when there is no previous authorization, including new members and members currently receiving treatment without prior authorizationInitial criteria satisfied

    • Prior authorization with response

      • Response evidence

        • Clinical response measure: Reduction in body surface area affected from baseline or improvement in signs and symptoms from baseline

    Required Prior Therapies

    StepStep therapy requirementApplies when
    1Prior biologic or targeted synthetic drug therapyThe adult member has previously received a biologic or targeted synthetic drug indicated for moderate to severe plaque psoriasis, such as Sotyktu or Otezla.
    StepStep therapy requirementApplies when
    2Prior phototherapy or conventional systemic treatmentFor members with at least 3% affected BSA, there must be an inadequate response or intolerance to phototherapy (such as UVB or PUVA) or pharmacologic treatment with methotrexate, cyclosporine, or acitretin. A documented clinical reason to avoid methotrexate, cyclosporine, and acitretin may be used instead.

    Quantity and Dosing Limits

    SILIQ (brodalumab) dosing limits
    FDA-approved labelingDosing limits may be consistent with FDA-approved labeling.
    Accepted compendiaDosing limits may be consistent with accepted compendia.
    Evidence-based guidelinesDosing limits may be consistent with evidence-based practice guidelines.
    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicySILIQ (brodalumab) coverage for moderate to severe plaque psoriasis
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 27, 2025
    Last ReviewJun 1, 2025
    Next Review DateN/A
    Key ActionPrecertification is required for SILIQ; providers should use the HMSA medical policy website fax form.
    SourceLink
    On This Page
    Coverage CriteriaClinical ThresholdsProvider Requirements and Approval RisksPolicy BackgroundInitial TherapyContinuation and ReauthorizationRequired Prior TherapiesQuantity and Dosing Limits
    Alternatively, a clinical reason to avoid pharmacologic treatment with methotrexate, cyclosporine, and acitretin must be documented.
    Step Therapy

    Phototherapy or Conventional Systemic Therapy Pathway

    For moderate to severe plaque psoriasis with at least 3% BSA affected, document an inadequate response or intolerance to phototherapy or conventional systemic treatment with methotrexate, cyclosporine, or acitretin.

    Documentation Required

    Initial Clinical Documentation

    At initial authorization, submit documentation supporting the member’s eligibility and medical necessity for SILIQ.

    • Member is an adult.
    • Diagnosis of moderate to severe plaque psoriasis.
    • Affected crucial body areas and/or the percentage of body surface area (BSA) affected, including documentation of at least 3% BSA when that pathway is used.
    • Relevant prior biologic, targeted synthetic, phototherapy, or conventional systemic treatment, including response, intolerance, or contraindication.
    Documentation Required

    Document Prior Treatment or Avoidance Rationale

    When relying on the 3% BSA pathway, document either inadequate response or intolerance to phototherapy or methotrexate, cyclosporine, or acitretin, or a clinical reason to avoid those systemic agents.

    • Examples supporting avoidance include chronic liver disease, drug interaction, treatment-related toxicity risk, pregnancy or plans for pregnancy, breastfeeding, significant comorbidity, hypersensitivity, or prior intolerance/adverse event.
    • The record should identify the specific prior treatment outcome or the clinical reason each applicable conventional systemic option is unsuitable.
    Documentation Required

    Continuation Documentation

    For reauthorization, document that the member was previously authorized by HMSA/CVS and achieved or maintains a positive clinical response to SILIQ.

    • Reduction in affected BSA from baseline; or
    • Improvement in signs and symptoms from baseline, such as itching, redness, flaking, scaling, burning, cracking, or pain.
    Documentation Required

    TB Screening Documentation

    For members naïve to biologic drugs or targeted synthetic drugs associated with increased TB risk, document a negative tuberculosis screening test within 12 months before initiating therapy.

    • Acceptable screening includes a tuberculosis skin test (TST) or interferon-gamma release assay (IGRA).
    • If screening is positive, document further evaluation confirming no active TB, such as a chest x-ray; latent TB requires treatment before SILIQ initiation.

    Unsupported block type: denial_risk שחסר?

    Denial Risk

    Initial Authorization Criteria Must Be Met

    Failure to satisfy the applicable initial-authorization pathway may result in denial. Members without previous authorization must meet the initial approval criteria, including the applicable adult plaque-psoriasis, prior-therapy, BSA, or crucial-area requirements.

    • A prior authorization is not assumed for new members or members already receiving treatment without prior authorization.
    • For the 3% BSA pathway, inadequate response/intolerance to qualifying therapy or a documented clinical reason to avoid it is required.
    Denial Risk

    Reauthorization Requires Clinical Response

    Reauthorization may be denied when prior HMSA/CVS authorization or a positive clinical response is not documented. Response must be shown by reduced BSA or improved baseline signs and symptoms.

    Denial Risk

    Prescriber Specialty Requirement

    Authorization may be denied when SILIQ is prescribed without the required dermatologist involvement. Ensure the prescriber is a dermatologist or document consultation with a dermatologist.

    At least 10% BSA: At least 10% of body surface area is affected≥10% BSA

  1. At least 3% BSA with additional criterion

    • Prior treatment failure or intolerance: Inadequate response or intolerance to phototherapy or pharmacologic treatment with methotrexate, cyclosporine, or acitretin
    • Clinical reason to avoid treatment: Clinical reason to avoid pharmacologic treatment with methotrexate, cyclosporine, and acitretin
    2. Reduced BSA or improved itching, redness, flaking, scaling, burning, cracking, or pain