CurrentMass General Brigham Health PlanPolicy N/A

Sotyktu (deucravacitinib) prior authorization for plaque psoriasis

Prior authorization policy for Sotyktu (deucravacitinib) under the pharmacy benefit for Commercial/Exchange members of Mass General Brigham Health Plan, detailing initial and continuation coverage criteria, limits, and documentation requirements.

Policy Summary

PayerMass General Brigham Health Plan

PolicySotyktu (deucravacitinib) prior authorization for plaque psoriasis

Policy CodePolicy N/A

Change TypeClarified administrative wording

Effective DateMay 1, 2025

Next Review DateMay 1, 2026

Key ActionObtain prior authorization and submit medical records demonstrating improvement or, for new members (≤90 days), records showing current treatment with the requested drug.

SourceLink

POLICY UPDATE CHANGES

Reauthorization wording changed to require 'submission of medical records (e.g., chart notes) demonstrating improvement' rather than previous phrasing.

Updated language for members new to the Plan regarding documentation when currently receiving treatment with the requested drug.

Commercial/Exchangeapplicable plan

24 monthsinitial and reauthorization approval period

1 tablet/dayquantity limit for Sotyktu

>=3% BSA or crucial areasdisease extent requirement for coverage

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Coverage Criteria for Sotyktu (deucravacitinib)

inv-01: Initial Therapy

Authorization may be granted when ALL of the following diagnosis-specific criteria have been met:

Moderate to severe plaque psoriasis criteria: 1) Diagnosis of moderate to severe plaque psoriasis; 2) At least 3% of body surface area (BSA) affected OR involvement of crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas); 3) Member meets ONE of the following: a) Minimum 4-week trial and failure, intolerance, or contraindication to ONE topical therapy (examples: corticosteroids (e.g., betamethasone, clobetasol), vitamin D analogs (e.g., calcitriol, calcipotriene), tazarotene, calcineurin inhibitors (e.g., tacrolimus, pimecrolimus), anthralin, coal tar); OR b) Member has severe psoriasis that warrants a biologic DMARD as first-line therapy.

For members new to the plan (coverage effective ≤ 90 days), submit medical records documenting the member is currently receiving the requested drug (excluding samples or manufacturer patient assistance programs).

inv-02: Continuation Therapy

Requests for reauthorization will be approved when ALL of the following criteria are met:

Continuation criteria: Submission of medical records (e.g., chart notes) demonstrating improvement in the member's condition as evidenced by low disease activity or improvement in signs and symptoms of the condition.24 months

Reauthorizations may be granted for up to 24 months; quantity limit of 1 tablet per day applies.

This policy applies to Sotyktu (deucravacitinib) under the pharmacy benefit and is specific to Commercial/Exchange members. It does not apply to MassHealth UPPL.

Initial Therapy Requirements

inv-11: Initial

Initial authorization criteria

Initial authorization: Member has a diagnosis of moderate to severe plaque psoriasis; ≥3% BSA affected OR crucial body areas involved; AND member has either: (a) completed a minimum 4-week trial and experienced failure, intolerance, or has a contraindication to ONE topical therapy (see examples), OR (b) has severe psoriasis warranting initiation of a biologic DMARD as first-line therapy. For members new to the plan (coverage effective ≤ 90 days), provide medical records documenting current treatment with the requested drug (excluding samples or manufacturer assistance).

Topical therapy examples: corticosteroids (e.g., betamethasone, clobetasol), vitamin D analogs (e.g., calcitriol, calcipotriene), tazarotene, calcineurin inhibitors (e.g., tacrolimus, pimecrolimus), anthralin, coal tar.

Reauthorization and Continuation Requirements

inv-12: Reauthorization

Reauthorization requirements and limits

Reauthorization: Submission of medical records demonstrating clinical improvement or low disease activity (e.g., chart notes documenting reduced signs/symptoms or low disease activity).24 months

Initial approvals and reauthorizations may be granted for up to 24 months. Quantity limit: Sotyktu 1 tablet per day.

Clinical Extent and Coding Details

inv-04: Body Surface Area (BSA)

BSA threshold>= 3% of body surface area

Alternative thresholdInvolvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

Role in coverage decisionMeets disease extent requirement for initial authorization when either BSA >=3% or crucial areas involved

Quantity Limits for Sotyktu

inv-13: Sotyktu tablet — 1 (tablet/day quantity limit)

Drug and formSotyktu tablet

Quantity limit1 tablet per day

Policy noteQuantity limit applies to both initial approvals and reauthorizations

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Sotyktu (deucravacitinib) when billed under the pharmacy benefit for Commercial/Exchange members.

Program Type: Prior Authorization
Plan: Commercial/Exchange members only
Benefit: Pharmacy benefit coverage

Step Therapy

Topical Therapy Prerequisite

Most members must have a trial and failure, intolerance, or contraindication to at least one topical therapy prior to authorization for moderate to severe plaque psoriasis.

Required prior topical therapies (one of): corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar
Exception: severe psoriasis where a biologic DMARD as first-line therapy is warranted

Definitions and Disease Severity

inv-10: Moderate to severe plaque psoriasis

Diagnosis requirementDiagnosis of moderate to severe plaque psoriasis

Disease extent>= 3% BSA affected OR involvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

Topical therapy prerequisiteMinimum 4-week trial and failure, intolerance, or contraindication to ONE topical therapy (examples: corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar)

Biologic-first exceptionMay bypass topical trial if member has severe psoriasis warranting biologic DMARD as first-line therapy

Background

Deucravacitinib (Sotyktu) is a TYK2 inhibitor approved for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.