CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Taltz (ixekizumab) — Coverage Criteria (Plaque Psoriasis, Psoriatic Arthritis, AS/axSpA)

Policy governs prior authorization, continuation, and clinical criteria for coverage of Taltz (ixekizumab) for plaque psoriasis (ages ≥6), psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTaltz (ixekizumab) — Coverage Criteria for PsO, PsA, AS/axSpA

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of indication, prior therapy history or reasons to avoid, and BSA/clinical response as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 motypical authorization duration

≥6minimum covered age for plaque psoriasis

≥10% BSApsoriasis coverage BSA threshold

TB test ≤6mTB screening requirement

Coverage Criteria for Taltz (ixekizumab)

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Plaque psoriasis (PsO) — Initial therapy

Plaque psoriasis (PsO) — Initial therapy; Authorization of 12 months may be granted for members ≥6 years when ALL of the following are met:

Authorization of 12 months may be granted for members 6 years of age or older who have previously received a biologic or targeted synthetic drug (e.g., Sotyktu, Otezla) indicated for the treatment of moderate to severe plaque psoriasis.

Authorization of 12 months may be granted for members 6 years of age or older for the treatment of moderate to severe plaque psoriasis when any of the following criteria is met:

Crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) are affected.

At least 10% of body surface area (BSA) is affected.

At least 3% of body surface area (BSA) is affected and the member meets any of the following criteria:

Member has had an inadequate response or intolerance to either 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).

Psoriatic arthritis (PsA) — Initial therapy

Psoriatic arthritis (PsA) — Initial therapy; Authorization of 12 months may be granted for adult members when ANY of the following pathway criteria are met:

Authorization of 12 months may be granted for adult members who have previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Otezla) indicated for active psoriatic arthritis.

Authorization of 12 months may be granted for adult members for treatment of active psoriatic arthritis when either of the following criteria is met:

Member has mild to moderate disease and meets one of the following criteria:

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 (see Appendix), or another conventional synthetic drug (e.g., sulfasalazine).

Ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (axSpA) — Initial therapy

Ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (axSpA) — Initial therapy; Authorization of 12 months may be granted for adult members when ALL/ANY of the following are met depending on pathway:

Authorization of 12 months may be granted for adult members who have previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Xeljanz) indicated for active ankylosing spondylitis or active axial spondyloarthritis.

Authorization of 12 months may be granted for adult members for treatment of active ankylosing spondylitis or active axial spondyloarthritis when any of the following criteria is met:

Member has had an inadequate response to at least two non-steroidal anti-inflammatory drugs (NSAIDs).

Member has an intolerance or contraindication to two or more NSAIDs.

Coding and Clinical Thresholds

Body Surface Area (BSA) thresholds — Plaque psoriasis (PsO)

Automatic coverage BSA threshold>= 10% of body surface area (BSA)

Conditional coverage BSA threshold>= 3% of body surface area (BSA) when accompanied by additional criteria

Additional criteria for 3% BSAInadequate response or intolerance to phototherapy (e.g., UVB, PUVA) or methotrexate, cyclosporine, or acitretin

Alternative qualifying criterion with 3% BSAClinical reason to avoid methotrexate, cyclosporine, or acitretin (see Appendix)

TB testing recency and requirements

Required TB testing windowDocumentation of a negative TB test within 6 months prior to initiating therapy for biologic/targeted synthetic–naïve members

Acceptable TB testsTuberculin skin test (PPD), interferon-gamma release assay (IGRA), or chest x-ray

Positive TB test actionsIf screening is positive, further testing to exclude active disease is required before treatment

Latent TB managementIf latent TB is identified, TB treatment must be started before initiating the requested medication

Provider Actions, Documentation, and Billing Notes

Prior Authorization

Prior authorization — 12‑month approvals when criteria met

Prior authorization may be granted for 12 months when the member meets the specific indication criteria for plaque psoriasis, psoriatic arthritis, or ankylosing/axial spondyloarthritis including prior biologic/targeted therapy history or failure/intolerance to specified conventional therapies.

Step Therapy

Step therapy / prior treatment expectations

For many indications, approval requires prior use of or exposure to other systemic, phototherapy, or conventional synthetic therapies (or documentation of contraindication/intolerance), or prior biologic/targeted synthetic therapy as specified by indication.

PsO: prior biologic/targeted synthetic drug OR inadequate response/intolerance to phototherapy or methotrexate/cyclosporine/acitretin (or clinical reason to avoid).
PsA: prior biologic/targeted synthetic drug OR inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD (or intolerance/contraindication).
AS/axSpA: prior biologic/targeted synthetic drug OR inadequate response to at least two NSAIDs (or intolerance/contraindication to two or more NSAIDs).

Documentation Required

Required clinical documentation for prior authorization

Initial requests must include chart notes or medical record documentation of affected area(s) and body surface area (BSA) for psoriasis, prior medications tried and responses (or clinical reasons to avoid), and for arthritis/axial disease prior medication history and response. Continuation requests must include documentation of clinical improvement from baseline.

PsO initial: chart notes documenting affected areas and BSA; prior medications and response or reason to avoid.
PsA/AS/axSpA initial: chart notes or claims history of prior medications tried and responses or reasons to avoid.
Continuation: documentation of decreased BSA and/or improvement in signs/symptoms (PsO) or positive clinical response for arthritis/axial disease.

Documentation Required

TB screening documentation (negative test within 6 months)

Document a negative tuberculosis (TB) test within 6 months prior to initiating therapy for persons naïve to biologic or targeted synthetic drugs; if TB testing is positive, document further testing to exclude active disease and treatment of latent TB prior to initiation.

Acceptable tests: PPD, IGRA, or chest x‑ray.
If screening is positive: confirm no active TB before treatment; do not administer medication if active TB is present; start latent TB treatment before initiation if applicable.

Denial Risk

Indications not listed are not covered

Requests for indications not listed as FDA‑approved indications or compendial uses are considered experimental/investigational and are not medically necessary; such requests may be denied.

Denial Risk

Active TB — do not administer

Do not administer the requested medication to members with active tuberculosis infection; a positive TB screen without documented completion of appropriate treatment or exclusion of active disease may result in denial.

Definitions and Clinical Terms

Crucial body areas — definition and implications

Definition of crucial body areasAnatomic sites where involvement may warrant systemic therapy despite lower BSA: hands, feet, face, neck, scalp, genitals/groin, and intertriginous areas

Clinical relevancePresence of psoriasis in these areas can meet criteria for systemic biologic therapy even when overall BSA is below standard thresholds

Documentation expectationInitial requests should include chart notes/medical record documentation of affected area(s) identifying these crucial sites

Body surface area (BSA) — definition and thresholds

BSA as a coverage criterionPercent of body surface area affected by psoriasis used to determine eligibility for systemic therapy

Primary threshold>= 10% BSA qualifies for treatment coverage without additional qualifiers

Lower-threshold pathway>= 3% BSA may qualify if accompanied by inadequate response/intolerance to phototherapy or methotrexate/cyclosporine/acitretin, or a clinical reason to avoid those agents

Provider documentationChart notes must document BSA percentage for initial requests and show improvement in BSA for continuation requests

OpenPayer

Taltz (ixekizumab) — Coverage Criteria (Plaque Psoriasis, Psoriatic Arthritis, AS/axSpA)

Coverage Criteria for Taltz (ixekizumab)

Coding and Clinical Thresholds

Provider Actions, Documentation, and Billing Notes

Background on Ixekizumab (Taltz)

Definitions and Clinical Terms