CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Otezla 2002 A Sgm P2022A

Prior authorization policy for Otezla (apremilast) for adult indications (plaque psoriasis, psoriatic arthritis, Behcet's disease) describing required documentation, prescriber specialties, initial and continuation approval criteria, dosing limits, concomitant therapy restrictions, and supportive appendices outlining topical steroid potency and contraindication examples.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOtezla 2002 A Sgm P2022A

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmission of chart notes, medical record documentation, or claims history supporting prior therapies, responses, or clinical reasons to avoid therapies is required to initiate prior authorization; continuation requests must include documentation of clinical improvement or response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

3Covered Indications (FDA-approved)

12Authorization duration (months)

3Prescriber specialties required

Coverage Summary

This policy is a prior authorization for Otezla (apremilast) covering adult FDA-approved indications: plaque psoriasis, active psoriatic arthritis, and oral ulcers associated with Behcet's disease. Coverage is covered_with_criteria — approvals require meeting the specified initial or continuation criteria (including prior therapies tried, inadequate response/intolerance, or clinical reasons to avoid therapies) and absence of exclusions. Standard authorization duration is 12 months. Medication must be prescribed by or in consultation with the required specialties: dermatologist for plaque psoriasis, rheumatologist or dermatologist for psoriatic arthritis, and rheumatologist for Behcet's disease. Dosing limits and a prohibition on concomitant biologic/targeted synthetic drugs apply.

Initial Therapy Criteria

Indications considered covered

Covered when ALL of the following are met and member has no exclusions:

Indication is one of the FDA-approved indications: adult plaque psoriasis; adult active psoriatic arthritis; adult oral ulcers associated with Behcet's disease

Plaque psoriasis (Initial authorization)

Authorization of 12 months may be granted when ONE of the following is met:

ONE of

Member has previously received a biologic or a targeted synthetic drug (e.g., Sotyktu) indicated for the treatment of plaque psoriasis.
Member has had an inadequate response or intolerance to ONE of: phototherapy (e.g., UVB, PUVA); topical therapies (e.g., medium or higher potency topical corticosteroids, calcineurin inhibitors, vitamin D analogs).
Member has a contraindication or clinical reason to avoid BOTH phototherapy and topical therapies (see Appendix A and Appendix B for examples).
Member has had an inadequate response to or intolerance to pharmacologic treatment with ONE of: methotrexate, cyclosporine, or acitretin.
Member has a clinical reason to avoid pharmacologic treatment with ALL of: methotrexate, cyclosporine, and acitretin (see Appendix B for examples).

Psoriatic arthritis (Initial authorization)

Authorization of 12 months may be granted for adult members when ONE of the following is met:

ANY of the following

Member has previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Xeljanz) indicated for active psoriatic arthritis.
Member has had an inadequate response to methotrexate, leflunomide, or another conventional synthetic drug (e.g., sulfasalazine) administered at an adequate dose and duration.
Member has an intolerance or contraindication to methotrexate or leflunomide, or another conventional synthetic drug (e.g., sulfasalazine) (see Appendix C for examples).
Member has enthesitis.

Behcet's disease (Initial authorization)

Authorization of 12 months may be granted for adult members when ONE of the following is met:

ANY of the following

Member has previously received a biologic indicated for the treatment of Behcet's disease.
Member has had an inadequate response to at least one nonbiologic medication for Behcet's disease (e.g., colchicine, systemic glucocorticoids, azathioprine).

Prescriber specialty requirements

Medication must be prescribed by or in consultation with:

Plaque psoriasis: dermatologist

Psoriatic arthritis: rheumatologist or dermatologist

Behcet's disease: rheumatologist

Dosage and administration limits

Approvals may be subject to dosing limits:

Approvals subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.

Continuation Therapy Criteria

Continuation/renewal criteria - Plaque psoriasis

Authorization of 12 months may be granted for members who achieve or maintain positive clinical response when ANY of the following improvement measures from baseline are met:

ANY of the following

Reduction in body surface area (BSA) affected from baseline
Improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling, burning, cracking, pain)

Continuation/renewal criteria - Psoriatic arthritis

Authorization of 12 months may be granted when there is improvement in ANY of the following from baseline:

ANY of the following

Number of swollen joints
Number of tender joints
Dactylitis
Enthesitis
Axial disease
Skin and/or nail involvement

Continuation/renewal criteria - Behcet's disease

Authorization of 12 months may be granted when the member achieves or maintains positive clinical response:

Improvement or maintenance of low disease activity or improvement in signs and symptoms of Behcet's disease (oral ulcers)

General exclusion / concurrency rule

For all indications:

Member cannot use the requested medication concomitantly with any other biologic drug or targeted synthetic drug.

Applies to all indications.

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Submission of chart notes, medical record documentation, or claims history supporting prior therapies, responses, or clinical reasons to avoid therapies is required to initiate prior authorization; continuation requests must include documentation of clinical improvement or response.

Documentation Required

Documentation for specific indications

Plaque psoriasis and psoriatic arthritis initial requests require chart notes, medical record documentation, or claims history documenting prior medications tried and response or clinical reason to avoid those therapies. Behcet's disease initial requests require chart notes, medical record documentation, or claims history supporting previous medications tried and response if applicable. Continuation requests for all indications require documentation of clinical improvement or positive clinical response.

Documentation Required

Prescriber specialty documentation

The medication must be prescribed by or in consultation with a clinician in the required specialty: dermatologist for plaque psoriasis; rheumatologist or dermatologist for psoriatic arthritis; rheumatologist for Behcet's disease. If the prescriber is not in the required specialty, documentation of consultation with the required specialist must be provided.

Billing Rule

Concomitant biologic/targeted synthetic drugs prohibited

Claims may be denied if Otezla (apremilast) is used concomitantly with any other biologic drug or targeted synthetic drug.

Denial Risk

Not covered for non-FDA/compendial indications

Indications not listed among the FDA-approved indications or compendial uses (i.e., uses other than adult plaque psoriasis, active psoriatic arthritis, or oral ulcers associated with Behcet's disease) are considered experimental/investigational and not medically necessary and should be denied.

Required documentation to initiate prior authorization includes chart notes, medical record documentation, or claims history supporting prior therapies tried, responses, or clinical reasons to avoid therapies; continuation requests must include documentation of clinical improvement or positive response. See Appendices A, B, and C for topical corticosteroid potency groupings and examples of clinical reasons/contraindications to avoid conventional systemic therapies. If the prescriber is not in a required specialty, include documentation of consultation or consultation notes with the required specialist.

Background

Background: The policy covers Otezla for adult plaque psoriasis, psoriatic arthritis, and oral ulcers in Behcet's disease and aligns approvals with prior therapies tried, documented inadequate response or intolerance, contraindications or clinical reasons to avoid alternatives, and documented clinical response for continuation. Appendices provide topical corticosteroid potency groupings (Appendix A) and examples of clinical reasons or contraindications to avoid conventional systemic therapies (Appendices B and C).

Definitions

Definition: Inadequate response or intoleranceClinical judgment supported by documentation that prior therapy did not achieve desired efficacy or was not tolerated.

OpenPayer

Otezla 2002 A Sgm P2022A

Coverage Summary

Initial Therapy Criteria

Continuation Therapy Criteria

Provider Actions & Requirements

Applicable Codes & References

Background

Clinical Evidence & References

Revision History