CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Apremilast (Otezla, Otezla XR) — Coverage Criteria

Defines prior authorization, prescriber specialties, documentation, and coverage criteria for apremilast (Otezla/Otezla XR) for Neighborhood Health Plan of Rhode Island members for specified indications when approval criteria are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyApremilast (Otezla, Otezla XR) — Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor or no change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of prior therapies, clinical response, or clinical reasons to avoid alternatives.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

>=6 yrsmin age (PsO, PsA)

20 kgmin pediatric weight

Noconcomitant therapy allowed?

Yesprescriber restriction

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Plaque Psoriasis (Initial therapy for members >=6 years)

Authorization of 12 months may be granted for members 6 years and older for treatment of plaque psoriasis when ANY of the following are met:

criteria: Member has had an inadequate response or intolerance to ONE of the following: phototherapy (e.g., UVB, PUVA) OR topical therapies (e.g., medium or higher potency topical corticosteroids, calcineurin inhibitors, vitamin D analogs).

phototherapy or topical therapies examples provided

criteria: Member has a contraindication or clinical reason to avoid BOTH phototherapy (e.g., UVB, PUVA) AND topical therapies (e.g., medium or higher potency topical corticosteroids, calcineurin inhibitors, vitamin D analogs).

see Appendix A for topical corticosteroid potency; clinical reason must be documented

criteria: Member has had an inadequate response or intolerance to ONE of the following pharmacologic treatments: methotrexate, cyclosporine, or acitretin.

document prior medications and response

criteria: Member has a documented clinical reason to avoid ALL of the following systemic agents: methotrexate, cyclosporine, and acitretin.

see Appendix B for examples of clinical reasons to avoid

Psoriatic Arthritis (Initial therapy for members >=6 years)

Authorization of 12 months may be granted when ANY of the following are met:

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

document dose/duration and response

criteria: Member has an intolerance or contraindication to methotrexate, leflunomide, or another conventional synthetic drug (e.g., sulfasalazine).

see Appendix B for contraindications; document clinical reason

criteria: Member has enthesitis.

clinical documentation required

Behçet's Disease (Adults)

Authorization of 12 months may be granted for adult members when:

criteria: Member has had an inadequate response to at least one nonbiologic medication for Behçet's disease (e.g., colchicine, systemic glucocorticoids, azathioprine).

document prior therapy and response

Immune Checkpoint Inhibitor-Related Toxicity (Immunotherapy-related psoriasis/psoriasiform diseases)

Authorization of 12 months may be granted when the member has moderate to severe disease and meets either of the following:

criteria: Member has had an inadequate response to medium or higher potency topical corticosteroids.

see Appendix A for potency definitions

criteria: Member has an intolerance or contraindication to medium or higher potency topical corticosteroids.

document clinical reason to avoid; see Appendix A

Continuation Criteria (All Indications)

Authorization of 12 months may be granted for members (including new members) who achieve or maintain a positive clinical response as evidenced by:

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

document baseline and follow-up

psa_response: Improvement in any of: number of swollen joints, number of tender joints, dactylitis, enthesitis, axial disease, skin and/or nail involvement, functional status, or C-reactive protein (CRP) from baseline.

document objective measures where possible

behcet_response: Low disease activity or improvement in signs and symptoms for Behçet's disease.

document clinical improvement

ici_response:

Behcet's disease — Authorization

Behcet's disease

Behcet's authorization: Authorization of 12 months may be granted for all adult members (including new members) who achieve or maintain a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition.12 months

applies to adults; clinical response required

Immunotherapy-related psoriasis/psoriasiform disease — Authorization

Immune checkpoint inhibitor-related toxicity

Immunotherapy-related authorization: Authorization of 12 months may be granted for all members (including new members) who are using the requested medication for immunotherapy-related psoriasis and psoriasiform diseases and who achieve or maintain a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms of the condition.12 months

clinical response required

Concurrent biologic/targeted synthetic therapy

Concomitant therapy restriction

Concomitant therapy prohibition: Member cannot use the requested medication concomitantly with any other biologic drug or targeted synthetic drug for the same indication.none

may trigger denial

Dosing limits

Dosing and administration

Dosing conformity: Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.per FDA/compendia/guidelines

document references adherence to labeling and guidelines

All indications for apremilast that are not explicitly listed in this policy — including uses outside of the FDA‑approved indications and the compendial uses referenced herein — are considered experimental/investigational and not medically necessary and are not covered.

Use of the requested medication concurrently with any other biologic drug or targeted synthetic agent for the same indication is not permitted.

Requests to use apremilast in combination with another biologic or targeted synthetic therapy for the same indication will be considered not medically necessary and may be denied.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Authorization of up to 12 months may be granted when specified clinical criteria for the applicable indication are met. For plaque psoriasis and psoriatic arthritis, 12-month authorizations may be granted for members who previously received an appropriate biologic or targeted synthetic agent and who meet the listed step-therapy criteria (inadequate response, intolerance, or contraindication to prior therapies). Approvals may be subject to dosing limits consistent with FDA labeling, accepted compendia, and evidence-based practice guidance. Requests for indications outside the FDA-approved and listed compendial uses are considered experimental/investigational and are not medically necessary. The requested medication may not be used concomitantly with any other biologic or targeted synthetic drug for the same indication.

Authorization duration: up to 12 months when criteria are met
Concomitant biologic/targeted synthetic use for the same indication is not allowed

Documentation Required

Required Documentation

Initial requests: Provide chart notes, medical record documentation, or claims history supporting previous medications tried (if applicable) and the member's response to those therapies. If a recommended therapy is not advisable, include documentation of the clinical reason to avoid that therapy (see Appendix B for examples such as pregnancy, liver disease, drug interactions, hypersensitivity, or other significant comorbidity). Continuation requests: Provide chart notes or medical record documentation demonstrating improvement in signs and symptoms or other evidence of a positive clinical response.

Initial requests: chart notes, medical records, or claims history showing prior therapies and response, or clinical reason to avoid recommended therapies
Continuation requests: documentation of improvement or maintained positive clinical response
Appendix B lists examples of clinical reasons to avoid pharmacologic agents (e.g., pregnancy, liver disease, drug interactions, breastfeeding, significant comorbidity)

Note

Consideration of Alternatives and Contraindications

Prescribers should consider alternatives and contraindications and use dosing consistent with FDA labeling and evidence-based guidelines. For plaque psoriasis, members must generally have had an inadequate response or intolerance to phototherapy or topical therapies, or to systemic agents (methotrexate, cyclosporine, acitretin), or present a clinical reason to avoid these treatments. For psoriatic arthritis, members should have had an inadequate response to or intolerance/contraindication to conventional synthetic DMARDs (e.g., methotrexate, leflunomide, sulfasalazine) or have enthesitis. Appendix B provides clinical reasons to avoid the listed alternatives (for example: alcohol use disorder or chronic liver disease, drug interactions, pregnancy or planning pregnancy, breastfeeding, significant comorbidity, hypersensitivity, or prior intolerance).

Follow FDA labeling and evidence-based practice guidance for dosing and selection
Step-therapy expectations: phototherapy, topical agents, and/or conventional systemic agents must be tried or have documented contraindication/intolerance as specified per indication
See Appendix B for acceptable clinical reasons to avoid alternatives

OpenPayer

Apremilast (Otezla, Otezla XR) — Coverage Criteria

Coverage Criteria for Apremilast

Drug Products and Codes

Provider Actions and Prior Authorization Requirements

Background

Definitions and Clinical Notes

Otezla	apremilast (brand)
Otezla XR	apremilast extended-release (brand)