Prior authorization required — demonstrate age, BSA, and prior systemic therapy trial

Many biologic and systemic psoriasis therapies require prior authorization. Approval generally requires documentation of the patient’s age meeting agent-specific thresholds, disease extent (commonly ≥10% BSA unless an exception applies), and prior trial and inadequate response, intolerance, or contraindication to at least one approved systemic therapy (e.g., methotrexate, cyclosporine, acitretin, or PUVA). Medication must be prescribed by or in consultation with a dermatologist.

• Document age per agent-specific thresholds (e.g., many biologics ≥6 years; some agents 18+; Tremfya weight requirement updated to ≥40 kg).
• Document disease extent (commonly ≥10% BSA) or exception criteria (extensive recalcitrant facial, pustular hand/foot, or genital involvement).
• Document prior trial and failure/intolerance of at least one approved systemic therapy unless contraindicated.
• Prescriptions must be by or in consultation with a dermatologist.

Prior authorization plus site-of-service review for biologic/infused agents

Prior authorization and a site-of-service review are required for listed biologic and infused agents; applicable HCPCS/J-codes and Q-codes are provided in the policy and site-of-service medical necessity rules apply for IV-administered drugs and for individuals aged 13 and older.

• Site-of-service medical necessity applies to medical benefit reviews and is reviewed for individuals aged 13 and older.
• IV-administered drugs are subject to site-of-service review and associated HCPCS/J-code listings in the policy.

Prior authorization must follow medical vs pharmacy benefit routing

Certain agents are managed under the medical benefit, pharmacy benefit, or both; prior authorization must follow the benefit routing for the specific agent (e.g., infliximab products are medical-benefit managed; many adalimumab and other biologics may be managed through pharmacy and/or medical benefits). Otezla XR coverage routing was added with pediatric age/weight criteria.

• Confirm whether the requested agent is medical-benefit managed (e.g., Avsola, Inflectra, Remicade, Renflexis) or pharmacy/medical managed per the policy lists.
• Ensure prior authorization request is submitted to the correct benefit (medical vs pharmacy) to avoid routing denials.
• Otezla XR was added to preferred alternatives and has coverage for individuals ≥6 years and ≥50 kg.

Prior authorization required for listed HCPCS/J/Q codes

Prior authorization is required for specific HCPCS/J/Q codes listed in the policy; requests for drugs represented by those codes must meet the policy’s medical necessity criteria to be approved.

• Applicable codes include J0139, J1745, J3590, and multiple Q-codes and biosimilar HCPCS codes listed in the coding section.
• Authorization requests billed under these codes must meet the agent-specific criteria in the policy.

Follow defined step-therapy tiers and document prior failures

Step therapy tiers are defined and providers must document required prior failures per the step hierarchy; some agents require failure of listed first-line agents before approval for second-line agents.

• Step tiers include TNF-α antagonists, IL-17 inhibitors, IL-23 inhibitors, TYK2 inhibitors, PDE-4 inhibitors and others.
• Approval for many second-line agents requires prior inadequate response or intolerance to specified first-line agents as detailed in the policy.

Document prior inadequate response/intolerance to systemic therapy

Coverage generally requires documentation of prior inadequate response, intolerance, or contraindication to at least one approved systemic therapy (e.g., methotrexate, cyclosporine, acitretin, or PUVA); for some agents additional specified biologic/oral agent failures are required.

• Document prior trial(s) and reason for discontinuation (inadequate response, intolerance, or contraindication).
• Some agents require failure/intolerance of specified biologics or multiple agents (refer to agent-specific sections).

Otezla XR added to preferred alternatives — document alternative therapy use

Otezla XR was added to the list of preferred alternatives for several biologic agents; providers should document use or contraindication of preferred alternatives when step-therapy rules reference them.

• Otezla XR is now listed as a preferred alternative for Bimzelx, Siliq, Cosentyx, Cimzia, and Ilumya per the 2026 update.
• If a preferred alternative is tried, document trial dates, dose, and clinical response or intolerance.

Adhere to updated preferred-product sequencing for step therapy

Providers must follow updated preferred-product sequencing and step requirements; multiple policies revisions updated preferred adalimumab biosimilars and infliximab sequencing that affect authorization prerequisites.

• Verify member’s formulary and preferred-product lists in the policy history before submitting authorization.
• Document trials of preferred biosimilars or infliximab products if required by the step sequence.

Submit clinical documentation of diagnosis, BSA, and prior treatments

Documentation submitted for authorization must support the diagnosis (e.g., chronic plaque psoriasis), BSA involvement, prior trials and failures/intolerance of listed systemic agents, and that the medication is prescribed by or in consultation with a dermatologist.

• Include documentation of BSA percent or description of special-site disease if <10% (extensive facial, pustular hands/feet, genital involvement).
• Include medication history noting agents tried, dates, doses, and reasons for discontinuation.

Include office visit notes with authorization request

Submit office visit notes that contain the diagnosis, relevant history, physical evaluation, and medication history to demonstrate that medical necessity criteria are met.

• Attach office visit notes showing current disease activity, prior therapies, and clinician rationale for the requested agent.

Provide clinical severity documentation (e.g., GPPGA, BSA) for pustular disease

Document clinical severity metrics where relevant (trial-defined thresholds such as GPPGA pustulation subscores or BSA) for severe variants like generalized pustular psoriasis; these data are relevant to medical necessity determinations for agents used in pustular disease.

• For GPP flare requests, document GPPGA pustulation subscore and BSA involvement consistent with trial inclusion (e.g., pustulation subscore ≥2 and ≥5% BSA when applicable).
• Provide objective severity measures (GPPASI, GPPGA, BSA) when available.

Follow FDA prescribing information and document dosing/monitoring

Prescribing must follow FDA dosage and administration; policy notes medications are subject to product prescribing information and monitoring requirements and member benefit limitations.

• Ensure dosing, frequency, and administration route align with FDA-approved prescribing information.
• Be aware of member-specific benefit limitations or custom formulary exceptions referenced in the policy.

Bill IV-administered drugs through the medical benefit

Claims for IV-administered drugs described in this policy must be processed through the medical benefit; submitting IV drugs through the pharmacy benefit or incorrect billing route may trigger denial.

• Submit IV-administered drug claims through the medical benefit only per policy instruction.
• Verify benefit routing prior to claim submission to avoid billing-route denials.

Site-of-service denials — ensure SOS criteria are met

Use of a non-preferred or non-medically necessary site of service when the site-of-service criteria are not met is considered not medically necessary and may be denied; initial course hospital-based outpatient infusion is medically necessary for first 90 days when indicated.

• If site-of-service criteria are not met (e.g., no clinical justification for hospital-based infusion), expect possible denial for site-of-service.
• Hospital-based outpatient site is considered medically necessary for the initial 90 days for initial course or re-initiation after ≥6 months when criteria are met.

Denial risk if required prior systemic or comparator trials are not documented

Requests for biologic agents may be denied if required prior trials of approved systemic therapies (e.g., methotrexate, cyclosporine, acitretin, PUVA) or specified comparator biologics are not documented.

• For many agents, document at least one prior systemic therapy trial unless contraindicated.
• Some agents require documented failure of specified biologics or multiple agents per agent-specific criteria.

Benefit routing can trigger denials — verify medical vs pharmacy management

Benefit routing (medical vs pharmacy) affects authorization; requests may be managed under different benefits depending on the agent, and routing to the incorrect benefit could result in denial or delayed approval.

• Confirm whether the agent is managed through the medical benefit (e.g., infliximab products) or pharmacy/medical benefit before submitting authorization.
• If routed incorrectly, resubmit to the correct benefit to avoid denial.

Denial triggers — unmet coverage, SOS, or formulary requirements

Coverage denials commonly occur when coverage criteria, site-of-service medical necessity criteria, or formulary-specific requirements (such as trials of preferred agents or step therapy) are not met; review policy details and member plan exceptions before submission.

• Check for plan-specific exceptions (custom open/preferred formularies) referenced in policy history and related policies.
• Document compliance with step-therapy, preferred-product sequencing, and SOS rules to reduce denial risk.