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    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsHMSA Bimzelx Coverage Policy Prior Auth | OpenPaye…
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    CurrentHawaii Medical Service Association (HMSA)Policy 04-2026

    Bimzelx (bimekizumab-bkzx) Coverage Criteria

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    HMSA coverage and prior authorization criteria for Bimzelx in adults with specified inflammatory dermatologic and rheumatologic conditions.

    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyBimzelx (bimekizumab-bkzx) Coverage Criteria
    Policy CodePolicy 04-2026
    Change TypeNo material change
    Effective DateJune 26, 2026
    Last ReviewApr 1, 2026
    Next Review DateNot specified
    Key ActionSubmit prior authorization requests using the fax form available on the HMSA medical specialty drug policy website.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5Covered indications

    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.

    12 monthsInitial authorization
    3% or 10% BSAPlaque psoriasis thresholds
    90 daysHidradenitis antibiotic trial
    RequiredPrior authorization

    Coverage Criteria

    Initial Therapy: Plaque Psoriasis

    Authorization of 12 months may be granted for adult members when either the prior-treatment pathway or the disease-severity pathway is met.

    ALL of the following

    • Member is an adult.

    • ONE of the following

      • Member has previously received a biologic or targeted synthetic drug (e.g., Sotyktu, Otezla) indicated for treatment of moderate to severe plaque psoriasis.

      • Moderate to severe plaque psoriasis and ONE of the following

        • Crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas) are affected.
        • At least 10% of body surface area (BSA) is affected.>= 10% BSA

        • At least 3% BSA and ONE of the following

          • At least 3% of BSA is affected.>= 3% BSA

          • ONE of the following

            • Member has had an inadequate response or intolerance to phototherapy (e.g., UVB, PUVA) or pharmacologic treatment with methotrexate, cyclosporine, or acitretin.
            • Member has a clinical reason to avoid pharmacologic treatment with methotrexate, cyclosporine, and acitretin (see Appendix).
    note":"Approval duration: 12 months."}

    Initial Therapy: Psoriatic Arthritis

    Authorization of 12 months may be granted for adult members when either the prior-treatment pathway or the active-disease pathway is met.

    ALL of the following

    • Member is an adult.

    • ONE of the following

      • Member has previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Otezla) indicated for active psoriatic arthritis.

      • Active psoriatic arthritis and ONE of the following

        • Mild to moderate disease and ONE of the following

          • ONE of the following

            • Member has had an inadequate response to methotrexate, leflunomide, or another conventional synthetic drug (e.g., sulfasalazine) administered at an adequate dose and duration.

    Initial Therapy: Ankylosing Spondylitis or nr-axSpA

    Authorization of 12 months may be granted for adult members when either the prior-treatment pathway or the NSAID-treatment pathway is met.

    ALL of the following

    • Member is an adult.

    • ONE of the following

      • Member has previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Xeljanz) indicated for active ankylosing spondylitis or active non-radiographic axial spondyloarthritis.

      • Active ankylosing spondylitis or active non-radiographic axial spondyloarthritis and ONE of the following

        • Member has had an inadequate response to at least two nonsteroidal anti-inflammatory drugs (NSAIDs).>= 2 NSAIDs

    Initial Therapy: Hidradenitis Suppurativa

    Authorization of 12 months may be granted for adult members when either the prior-treatment pathway or the oral-antibiotic pathway is met.

    ALL of the following

    • Member is an adult.

    • ONE of the following

      • Member has previously received a biologic (e.g., Cosentyx, Humira) indicated for treatment of moderate to severe hidradenitis suppurativa.

      • Moderate to severe hidradenitis suppurativa and ONE of the following

        • Member has had an inadequate response to an oral antibiotic used for the treatment of hidradenitis suppurativa for at least 90 days (e.g., clindamycin, metronidazole, moxifloxacin, rifampin, or tetracyclines).>= 90 days

    Continuation and Reauthorization

    For members without a previous authorization or precertification, including new members and members currently receiving treatment without prior authorization, the initial-therapy criteria in Section D must be met. Reauthorization may be granted for 12 months when the member was previously authorized by HMSA/CVS for Bimzelx and has achieved or maintained a positive clinical response, evidenced by low disease activity or improvement in signs and symptoms, with the applicable indication-specific response documented.

    ONE applicable pathway

    • No previous authorization or precertification: Member meets the applicable initial-therapy criteria in Section D.

    • Plaque psoriasis reauthorization

      • Member was previously authorized by HMSA/CVS for Bimzelx.
      • Member achieves or maintains a positive clinical response, evidenced by low disease activity or improvement in signs and symptoms.

      • ONE of the following improvement criteria

    Do not administer the requested medication to members with active tuberculosis (TB) infection. If testing indicates latent TB, TB treatment must be started before initiation of the requested medication.

    Member cannot use Bimzelx concomitantly with any other biologic drug or targeted synthetic drug for the same indication.

    Key Threshold
    Plaque psoriasis BSA thresholdAt least 10% BSA, or at least 3% BSA with an inadequate response/intolerance to phototherapy or methotrexate, cyclosporine, or acitretin, or a clinical reason to avoid those drugs.
    Key Threshold
    Required oral-antibiotic trial for HSAt least 90 days
    Key Requirement
    TB screening timingDocumented negative TB test within 12 months before initiating therapy for members naïve to biologic drugs or targeted synthetic drugs associated with increased TB risk.

    Initial Therapy Criteria

    Initial Therapy: Plaque Psoriasis

    Covered for adult members with moderate to severe plaque psoriasis when one of the following pathways is met.

    Qualifying pathway

    • Previous biologic or targeted synthetic drug: Member previously received a biologic or targeted synthetic drug, such as Sotyktu or Otezla, indicated for treatment of moderate to severe plaque psoriasis.

    • Disease severity or treatment pathway

      • Crucial body areas, including the hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas, are affected.
      • Extensive disease: At least 10% of body surface area is affected.>=10% BSA

    Continuation and Reauthorization

    Continuation and Reauthorization

    Members without previous authorization must meet initial-approval criteria. Previously authorized members may receive a 12-month reauthorization when the applicable positive clinical response is documented.

    Initial approval or reauthorization

    • No previous authorization: Member has no previous authorization or precertification for Bimzelx, including a new member or a member currently receiving treatment without prior authorization, and meets the applicable initial-approval criteria.

    • Previous HMSA/CVS authorization and positive response

      • Plaque psoriasis response: Reduction in affected BSA from baseline or improvement in signs and symptoms such as itching, redness, flaking, scaling, burning, cracking, or pain.
      • Psoriatic arthritis response:

    Clinical Thresholds and Screening Requirements

    Plaque Psoriasis: Applicable BSA Thresholds
    10% BSA pathwayAt least 10% of body surface area is affected.
    3% BSA pathwayAt least 3% of body surface area is affected.
    Additional requirement for 3% BSAAt 3% BSA, the member must also have an inadequate response or intolerance to phototherapy or methotrexate, cyclosporine, or acitretin, or a clinical reason to avoid those pharmacologic treatments.
    Hidradenitis Suppurativa: Minimum Trial Duration
    Minimum oral-antibiotic trialAt least 90 days.
    Required responseInadequate response to an oral antibiotic used to treat hidradenitis suppurativa.

    Provider Requirements and Action Items

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for Bimzelx. Submit the request using the fax form available on the HMSA medical specialty drug policy website.

    Step Therapy

    Plaque Psoriasis Prior Therapy

    For moderate to severe plaque psoriasis, document the qualifying prior therapy or the applicable clinical exception. Authorization may be granted for 12 months when the member has previously received an indicated biologic or targeted synthetic drug, or when the disease-severity and prior-treatment criteria below are met.

    • Previous biologic or targeted synthetic drug indicated for moderate to severe plaque psoriasis, such as Sotyktu or Otezla.
    • Crucial body area involvement, such as the hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas.
    • At least 10% BSA affected.
    • At least 3% BSA affected plus either inadequate response or intolerance to phototherapy or methotrexate, cyclosporine, or acitretin; or a documented clinical reason to avoid those pharmacologic treatments.

    Policy Background

    Bimzelx (bimekizumab-bkzx) is covered for adult members with moderate to severe plaque psoriasis, active psoriatic arthritis, active non-radiographic axial spondyloarthritis with objective signs of inflammation, active ankylosing spondylitis, or moderate to severe hidradenitis suppurativa. Coverage is subject to the applicable indication-specific clinical criteria, documentation requirements, prescriber specialty requirements, and exclusions. Initial authorization generally requires qualifying prior therapy, treatment intolerance or contraindication, disease severity, or specified disease involvement; reauthorization is based on documented maintenance or improvement of clinical response.

    Definitions and Abbreviations

    nr-axSpA
    TermNon-radiographic axial spondyloarthritis (nr-axSpA).
    DefinitionActive non-radiographic axial spondyloarthritis with objective signs of inflammation.
    Covered populationAdult patients with active nr-axSpA and objective signs of inflammation.
    BSA
    DefinitionBody surface area (BSA) affected by plaque psoriasis.
    Extensive disease thresholdAt least 10% of BSA is affected.
    Limited disease thresholdAt least 3% of BSA is affected when paired with an additional qualifying treatment-response, intolerance, contraindication, or clinical-avoidance criterion.

    Step-Therapy Requirements

    Disease pathwayStep-therapy requirementException or alternative
    Crucial body areas affected
    Use or avoid specified prior therapies
    For at least 3% BSA affected
    Inadequate response or intolerance to phototherapy, methotrexate, cyclosporine, or acitretin
    At least 3% BSA affected
    Clinical reason to avoid methotrexate, cyclosporine, and acitretin
    At least 10% BSA affected
    No additional prior-therapy requirement stated
    Disease severity or patternStep-therapy requirementException or alternative
    Mild to moderate psoriatic arthritis
    Inadequate response to methotrexate, leflunomide, or another conventional synthetic drug at an adequate dose and duration
    Mild to moderate psoriatic arthritis
    Intolerance or contraindication to methotrexate, leflunomide, or another conventional synthetic drug
    Mild to moderate psoriatic arthritis with enthesitis or predominantly axial disease
    No conventional synthetic-drug trial required under this pathway
    Severe psoriatic arthritis
    Severe disease qualifies as an alternative pathway
    Qualifying pathwayStep-therapy requirementException or alternative
    Active ankylosing spondylitis or non-radiographic axial spondyloarthritis
    Inadequate response to at least two NSAIDs
    Active ankylosing spondylitis or non-radiographic axial spondyloarthritis
    Intolerance or contraindication to two or more NSAIDs
    Qualifying pathwayStep-therapy requirementException or alternative
    Moderate to severe hidradenitis suppurativa
    Inadequate response to an oral antibiotic used for hidradenitis suppurativa for at least 90 days
    Moderate to severe hidradenitis suppurativa
    Intolerance or contraindication to oral antibiotics used for hidradenitis suppurativa
    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyBimzelx (bimekizumab-bkzx) Coverage Criteria
    Policy CodePolicy 04-2026
    Change TypeNo material change
    Effective DateJune 26, 2026
    Last ReviewApr 1, 2026
    Next Review DateNot specified
    Key ActionSubmit prior authorization requests using the fax form available on the HMSA medical specialty drug policy website.
    SourceLink
    On This Page
    Coverage CriteriaInitial Therapy CriteriaContinuation and ReauthorizationClinical Thresholds and Screening RequirementsProvider Requirements and Action ItemsPolicy BackgroundDefinitions and AbbreviationsStep-Therapy Requirements
  1. Member has an intolerance or contraindication to methotrexate or leflunomide (see Appendix), or another conventional synthetic drug (e.g., sulfasalazine).
  2. Member has enthesitis or predominantly axial disease.
  3. Member has severe disease.
    4. note":"Approval duration: 12 months."}
    Member has an intolerance or contraindication to two or more NSAIDs.>= 2 NSAIDs
    note":"Approval duration: 12 months."}
    Member has an intolerance or contraindication to oral antibiotics used for the treatment of hidradenitis suppurativa.
    note":"Approval duration: 12 months."}
    Reduction in BSA affected from baseline.
  4. Improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling, burning, cracking, or pain).

  5. Psoriatic arthritis reauthorization

    • Member was previously authorized by HMSA/CVS for Bimzelx.
    • Member achieves or maintains a positive clinical response, evidenced by low disease activity or improvement in signs and symptoms.
    • Improvement from baseline in any of the following: number of swollen joints, number of tender joints, dactylitis, enthesitis, axial disease, skin and/or nail involvement, functional status, or C-reactive protein (CRP).

  6. Ankylosing spondylitis or nr-axSpA reauthorization

    • Member was previously authorized by HMSA/CVS for Bimzelx.
    • Member achieves or maintains a positive clinical response, evidenced by low disease activity or improvement in signs and symptoms.
    • Improvement from baseline in any of the following: functional status, total spinal pain, inflammation (e.g., morning stiffness), swollen joints, tender joints, or C-reactive protein (CRP).

  7. Hidradenitis suppurativa reauthorization

    • Member was previously authorized by HMSA/CVS for Bimzelx.
    • Member achieves or maintains a positive clinical response, evidenced by low disease activity or improvement in signs and symptoms.

    • ONE of the following improvement criteria

      • Reduction in abscess and inflammatory nodule count from baseline.
      • Reduced formation of new sinus tracts and scarring.
      • Decrease in frequency of inflammatory lesions from baseline.
      • Reduction in pain from baseline.
      • Reduction in suppuration from baseline.
      • Improvement in frequency of relapses from baseline.
      • Improvement in quality of life from baseline.
      • Improvement on a disease severity assessment tool from baseline.
    8. note":"Reauthorization duration: 12 months."}
  8. Limited BSA with inadequate response or intolerance: At least 3% of body surface area is affected and the member has had an inadequate response or intolerance to phototherapy or pharmacologic treatment with methotrexate, cyclosporine, or acitretin.>=3% BSA
  9. Limited BSA with clinical reason to avoid treatment: At least 3% of body surface area is affected and the member has a clinical reason to avoid pharmacologic treatment with methotrexate, cyclosporine, and acitretin.>=3% BSA

    Examples include chronic liver disease, drug interaction, treatment-related toxicity risk, pregnancy or planned pregnancy, breastfeeding, significant comorbidity, hypersensitivity, or prior intolerance/adverse event.

    10. Initial Therapy: Psoriatic Arthritis

    Covered for adult members with active psoriatic arthritis when one of the following pathways is met.

    Qualifying pathway

    • Previous biologic or targeted synthetic drug: Member previously received a biologic or targeted synthetic drug, such as Rinvoq or Otezla, indicated for active psoriatic arthritis.

    • Disease severity or conventional-therapy pathway

      • Mild to moderate disease

        • Inadequate response to conventional synthetic therapy: Member has had an inadequate response to methotrexate, leflunomide, or another conventional synthetic drug, such as sulfasalazine, administered at an adequate dose and duration.
        • Intolerance or contraindication: Member has an intolerance or contraindication to methotrexate, leflunomide, or another conventional synthetic drug.
        • Disease pattern: Member has enthesitis or predominantly axial disease.
      • Severe disease: Member has severe psoriatic arthritis.

    Initial Therapy: Ankylosing Spondylitis or nr-axSpA

    Covered for adults with active ankylosing spondylitis or active non-radiographic axial spondyloarthritis when one of the following pathways is met.

    Qualifying pathway

    • Previous biologic or targeted synthetic drug: Member previously received a biologic or targeted synthetic drug, such as Rinvoq or Xeljanz, indicated for active ankylosing spondylitis or active non-radiographic axial spondyloarthritis.
    • Inadequate response to NSAIDs: Member has had an inadequate response to at least two nonsteroidal anti-inflammatory drugs.>=2 NSAIDs
    • NSAID intolerance or contraindication: Member has an intolerance or contraindication to two or more nonsteroidal anti-inflammatory drugs.>=2 NSAIDs

    Initial Therapy: Hidradenitis Suppurativa

    Covered for adults with moderate to severe hidradenitis suppurativa when one of the following pathways is met.

    Qualifying pathway

    • Previous biologic: Member previously received a biologic, such as Cosentyx or Humira, indicated for treatment of moderate to severe hidradenitis suppurativa.
    • Inadequate response to oral antibiotic: Member has had an inadequate response to an oral antibiotic used for the treatment of hidradenitis suppurativa for at least 90 days, including clindamycin, metronidazole, moxifloxacin, rifampin, or a tetracycline.>=90 days
    • Oral antibiotic intolerance or contraindication: Member has an intolerance or contraindication to oral antibiotics used for the treatment of hidradenitis suppurativa.
    Improvement from baseline in any of the following: swollen joints, tender joints, dactylitis, enthesitis, axial disease, skin or nail involvement, functional status, or C-reactive protein.
  10. AS or nr-axSpA response: Improvement from baseline in functional status, total spinal pain, inflammation such as morning stiffness, swollen joints, tender joints, or C-reactive protein.
  11. Hidradenitis suppurativa response: Reduction in abscess and inflammatory nodule count; reduced formation of new sinus tracts or scarring; decreased frequency of inflammatory lesions; reduction in pain or suppuration; improved relapse frequency; improved quality of life; or improvement on a disease-severity assessment tool.
    12. Alternative pathway
    Intolerance or contraindication to oral antibiotics used to treat hidradenitis suppurativa.
    Tuberculosis Screening: Required Timeframe
    Screening timeframeWithin 12 months before initiating therapy.
    Screening testA documented negative tuberculosis test, including a tuberculosis skin test (TST) or interferon-release assay (IGRA).
    Positive screening resultFurther testing must confirm that active tuberculosis is absent; if latent tuberculosis is present, treatment must begin before therapy initiation.
    Step Therapy

    Psoriatic Arthritis Prior Therapy

    For active psoriatic arthritis, document prior conventional synthetic therapy or an applicable exception. Authorization may also be granted for members with enthesitis or predominantly axial disease, or severe disease.

    • In mild to moderate disease, inadequate response to methotrexate, leflunomide, or another conventional synthetic drug, such as sulfasalazine, at an adequate dose and duration.
    • In mild to moderate disease, intolerance or contraindication to methotrexate, leflunomide, or another conventional synthetic drug.
    • Alternatively, the member has enthesitis or predominantly axial disease, or has severe disease.
    • A prior biologic or targeted synthetic drug indicated for active psoriatic arthritis, such as Rinvoq or Otezla, also qualifies for the 12-month authorization pathway.
    Step Therapy

    Axial Spondyloarthritis Prior Therapy

    For active ankylosing spondylitis or non-radiographic axial spondyloarthritis, document inadequate response to NSAIDs or an exception based on intolerance or contraindication.

    • Inadequate response to at least two NSAIDs.
    • Intolerance or contraindication to two or more NSAIDs.
    • A prior biologic or targeted synthetic drug indicated for active ankylosing spondylitis or active non-radiographic axial spondyloarthritis, such as Rinvoq or Xeljanz, also qualifies for the 12-month authorization pathway.
    Step Therapy

    Hidradenitis Suppurativa Prior Therapy

    For moderate to severe hidradenitis suppurativa, document the required oral-antibiotic trial or the applicable exception. Authorization may be granted for 12 months when the member has previously received an indicated biologic or meets the oral-antibiotic criteria.

    • Inadequate response to an oral antibiotic used to treat hidradenitis suppurativa for at least 90 days, such as clindamycin, metronidazole, moxifloxacin, rifampin, or a tetracycline.
    • Intolerance or contraindication to oral antibiotics used to treat hidradenitis suppurativa.
    • A prior indicated biologic, such as Cosentyx or Humira, also qualifies for the 12-month authorization pathway.
    Documentation Required

    Plaque Psoriasis Documentation

    For initial plaque psoriasis requests, submit chart notes or medical-record documentation identifying the affected areas and the affected BSA, when applicable. For continuation requests, document decreased BSA and/or improvement in signs and symptoms.

    • Initial requests must also include documentation or claims history of previous medications tried and response to therapy, when applicable.
    • If a prior therapy is not advisable, document the clinical reason to avoid it.
    Documentation Required

    Other Indication Documentation

    For initial requests for psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, or hidradenitis suppurativa, submit chart notes, medical-record documentation, or claims history supporting previous medications tried and the response. For continuation requests, document positive clinical response.

    • If prior therapy is not advisable, document the clinical reason to avoid it.
    • Documentation should support the applicable diagnosis and the qualifying prior-treatment requirement.
    Documentation Required

    Tuberculosis Screening Documentation

    For members who are biologic-drug or targeted-synthetic-drug naive and receiving therapy associated with increased TB risk, document a negative TB test within 12 months before initiating therapy.

    • An acceptable screening test may be a tuberculosis skin test (TST) or interferon-release assay (IGRA).
    • If screening is positive, complete further testing, such as a chest x-ray, to confirm that active TB is absent.
    • If latent TB is present, TB treatment must begin before Bimzelx is initiated.
    Note

    Prescriber Specialty Required

    Bimzelx must be prescribed by or in consultation with the indicated specialist for the member’s condition.

    • Dermatologist: plaque psoriasis, psoriatic arthritis, and hidradenitis suppurativa.
    • Rheumatologist: psoriatic arthritis, hidradenitis suppurativa, ankylosing spondylitis, and non-radiographic axial spondyloarthritis.
    Note

    Physician Reconsideration

    If HMSA/CVS determines that the medical-necessity criteria are not met, the treating physician may request reconsideration of the determination. Include supporting documentation addressing the member’s diagnosis, prior treatment, clinical response or exception, and any other relevant medical-necessity facts.

    Denial Risk

    Active or Untreated Tuberculosis

    Do not administer Bimzelx to a member with active TB infection. A positive screening result requires further evaluation to rule out active disease; if latent TB is confirmed, treatment must be started before Bimzelx initiation.

    Denial Risk

    No Concurrent Same-Indication Therapy

    The member may not use Bimzelx concomitantly with another biologic drug or targeted synthetic drug for the same indication.

    Denial Risk

    Criteria or Exclusion Not Satisfied

    Coverage is subject to all approval criteria and the absence of exclusions. Requests may be denied when the applicable indication, prior-treatment requirement, documentation, specialist requirement, or other policy condition is not satisfied.

    • Confirm that the requested use meets the applicable plaque psoriasis, psoriatic arthritis, axial spondyloarthritis, or hidradenitis suppurativa criteria.
    • Confirm that no policy exclusion or prohibited concomitant therapy applies.
    Note

    Services Outside Policy Coverage

    Benefit determinations are subject to the member’s contract language, which controls if it conflicts with these guidelines. HMSA has determined that services not covered under this Medical Policy will generally not be medically necessary under Hawaii law; a treating physician may request reconsideration with supporting documentation.

    TST or IGRA
    TSTTuberculosis skin test used for tuberculosis screening.
    IGRAInterferon-release assay used for tuberculosis screening.
    Policy screening requirementFor applicable members, provide a documented negative TST or IGRA within 12 months before initiating therapy.