Medical necessity and site-of-service criteria for pharmacologic (including biologic and oral) treatments of plaque and other forms of psoriasis for Premera members; includes step therapy, age/weight thresholds, and site-of-service review for IV/injectable agents.
Key ActionObtain prior authorization per drug-specific coverage criteria; initial approvals may be up to 12 months and reauthorization up to 12 months contingent on continued clinical response.
Added coverage criteria for Otezla XR (apremilast extended release) for the treatment of psoriasis in individuals aged 6 years and older and weigh at least 50 kg.
Added Otezla XR to list of preferred alternatives for Bimzelx (bimekizumab-bkzx), Siliq (brodalumab), Cosentyx (secukinumab), Cimzia (certolizumab-pegol), and Ilumya (tildrakizumab-asmn).
Updated coverage criteria for Tremfya (guselkumab) to include individuals weigh at least 40 kg.
Added ustekinumab-aauz as a non-preferred product.
Removed coverage criteria for Yuflyma (adalimumab-aaty) as product has been discontinued.
Updated Simlandi (adalimumab-ryvk), adalimumab-ryvk, adalimumab-adbm [NDCs starting with 82009] from preferred products to non-preferred products.
Updated coverage criteria for Tremfya (guselkumab) to include individuals weigh at least 40 kg and updated age requirement to 6 years or older earlier in history.
Added coverage criteria for Otezla XR (apremilast extended release) for individuals aged 6 years and older and weighing at least 50 kg.
Added HCPCS codes Q5098, Q5099, Q5100, Q5137, Q9996, Q9998, Q9999, J2327, and Q5164 at various dates.
Jun. 1, 2026effective date
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.
May 12, 2026last revised
>=10% BSABSA threshold
Multiplesite-of-service drugs
12 monthsinitial auth length
6+age min for some biologics
Coverage Criteria and Medical Necessity
Example: Enbrel (etanercept) — Initial therapy
Covered when ALL of the following are met for many first-line agents (example: Enbrel):
Enbrel criteria: Individual aged 4 years or older AND diagnosis of chronic plaque psoriasis involving at least 10% body surface area (BSA) (exceptions allowed for extensive recalcitrant facial involvement, pustular hands/feet, or genital involvement that interferes with function) AND history of an adequate trial and treatment failure with at least 1 approved systemic therapy (e.g., methotrexate, cyclosporine, acitretin, or PUVA) unless contraindicated or not tolerated AND medication is being prescribed by or in consultation with a dermatologist.BSA >= 10%
Exceptions for facial, pustular hands/feet, or genital involvement
IL-class agents — Initial therapy
Covered when ALL of the following are met for IL-17/IL-12/23/IL-23 agents (examples: Taltz, Stelara, Skyrizi):
Typical IL-class agent: Individual meets agent-specific minimum age (examples: many IL-12/23 inhibitors specified age >=6 years; some IL-23/IL-17 agents specified age 6 or 18 depending on product) AND diagnosis of chronic plaque psoriasis involving at least 10% BSA (exceptions allowed for special-site disease) AND history of an adequate trial and treatment failure with at least 1 approved systemic therapy (e.g., methotrexate, cyclosporine, acitretin, or PUVA) unless contraindicated or not tolerated AND medication is being prescribed by or in consultation with a dermatologist.Agent-specific age/weight/BSA
Some agents require prior failure of specific biologics before coverage (see product-specific sections).
Second-line IL-17
Second-line / escalation coverage rules include additional prior biologic failures:
IL-17 second-line (Bimzelx): Individual aged 18 years or older AND diagnosis of chronic plaque psoriasis involving at least 10% BSA (exceptions allowed) AND history of an adequate trial and treatment failure with at least 1 approved systemic therapy unless contraindicated or not tolerated AND inadequate response or intolerance to at least 1 listed agents (examples include Enbrel, adalimumab biosimilars/brands, Otezla or Otezla XR, Skyrizi, Sotyktu, Stelara family, Taltz, Tremfya) AND medication is being prescribed by or in consultation with a dermatologist.Prior inadequate response to at least 1 agent from listed set
Agent list specified in policy.
Emergent use of infliximab products
Emergent use:
Emergent infliximab use: Avsola and Inflectra (and other infliximab products including Remicade, Renflexis, and Janssen unbranded infliximab) may be considered medically necessary as emergent treatment for severe pustular, exfoliative, or inflammatory psoriasis without prior use or failure/intolerance of a first-line drug.severe pustular/exfoliative disease
Applies to infliximab products; subject to site-of-service and medical benefit management.
Site-of-service criteria
Site-of-service medical necessity logic for IV/injectable administration (applies to medical benefit reviews):
Medically necessary sites: Preferred medically necessary sites: physician's office, infusion center, or home infusion. Hospital-based outpatient setting is considered medically necessary for the initial 90 days of an infusion course or for re-initiation after >=6 months off therapy, or when no outpatient infusion center is available within 50 miles or no contracted home infusion agency will travel to the home; hospital site is also appropriate when the individual has clinical risk factors increasing infusion risk (e.g., known cardiac or significant pulmonary disease, unstable renal function, difficult vascular access, acute mental status changes, history of severe adverse drug reactions/anaphylaxis) or for grade 3–4 cytokine release syndrome with imminent inpatient admission.initial 90 days or re-initiation after >=6 months; CRS grade 3-4 criteria
Claims for IV-administered drugs must be processed through the medical benefit.
Not medically necessary when criteria unmet (site-of-service exclusion)
Site-of-service exclusion
Not medically necessary sites: Hospital-based outpatient infusion and injectable therapy services are considered not medically necessary when the site-of-service criteria in this policy are not met.site-of-service criteria not met
This policy does not address inpatient administration; IV administrations billed must be processed through the medical benefit.
Agent-specific medical necessity criteria (generalized)
Covered when ALL of the following are met (agent-specific variations apply):
Age: Individual meets agent-specific minimum age (examples: many IL-12/23 inhibitors specified age >=6 years; some agents require >=18 years).age as stated per agent
See agent-specific sections.
Disease extent or severity: Diagnosis of chronic plaque psoriasis involving at least 10% body surface area (BSA) OR meeting exception criteria for extensive recalcitrant facial involvement, pustular involvement of hands/feet, or genital involvement that interferes with function.>=10% BSA (exceptions allowed)
Policy lists exceptions that permit approval with <10% BSA.
Prior systemic therapy: History of an adequate trial and treatment failure with >=1 approved systemic therapy (e.g., methotrexate, cyclosporine, acitretin, or PUVA) unless contraindicated or not tolerated.
Siliq (brodalumab) criteria
Siliq (brodalumab) may be considered medically necessary when ALL:
Age: Individual aged 18 years or older.>=18 years
BSA or exceptions: Chronic plaque psoriasis involving at least 10% BSA OR exception criteria (extensive recalcitrant facial involvement, pustular hands/feet, or genital involvement that interferes with function).>=10% BSA or exception
Prior therapies: History of an adequate trial and treatment failure with at least 1 approved systemic therapy unless contraindicated or not tolerated.>=1 systemic trial
Medication prescribed by or in consultation with a dermatologist is required.
Cosentyx (secukinumab) criteria (partial)
Cosentyx (secukinumab) may be considered medically necessary when ALL:
Age: Individual aged 6 years or older.>=6 years
TNF-alpha antagonists criteria
TNF-alpha antagonists may be considered medically necessary when ALL:
Age: Individual aged 18 years or older (for listed TNF agents).>=18 years
BSA: Chronic plaque psoriasis involving at least 10% BSA OR meeting exception criteria.>=10% BSA or exception
Prior systemic therapy: History of an adequate trial and treatment failure with >=1 approved systemic therapy unless contraindicated or not tolerated.>=1 systemic trial
Prior biologic trials:
Infliximab-specific requirements
Infliximab products - additional conditions
Site of service review: Infliximab (Janssen unbranded), Remicade, Avsola, Inflectra, and Renflexis are managed through the medical benefit and are subject to site-of-service review/documentation for administration.site-of-service documentation
Applies to listed infliximab products; hospital outpatient criteria apply per site-of-service policy.
Clinical trial-based criteria and evidence relevant to coverage decisions for spesolimab and biologics in pustular psoriasis and plaque psoriasis.
EFFISAYIL 1 inclusion: Adults aged 18-75 with history of generalized pustular psoriasis (GPP) per ERASPEN criteria and current moderate-to-severe flare defined as GPPGA pustulation subscore >=2 AND >=5% BSA involvement were eligible for the EFFISAYIL 1 trial.GPPGA pustulation subscore >=2; BSA >=5%
Supports rapid-response indication for spesolimab (primary endpoint at Week 1).
EFFISAYIL 1 primary endpoint: Primary endpoint was GPPGA pustulation subscore of 0 at the end of Week 1; spesolimab demonstrated benefit vs placebo (54% vs 6%).Week 1 outcome
Clinically meaningful rapid response in trial; responders could receive open-label doses or extension participation.
Maintenance/extension eligibility:
Plaque psoriasis biologic and oral agent evidence summaries
Pivotal trial outcomes for systemic biologics in moderate-to-severe plaque psoriasis used to support clinical value.
Adalimumab (Humira) evidence: Randomized trials demonstrated superior PASI-75 responses versus placebo and versus methotrexate (e.g., CHAMPION: 80% vs 36% at week 16); responses were sustained in maintenance phases and treatment was generally well tolerated.PASI-75 at specified weeks
Ustekinumab (Stelara) evidence: PHOENIX I/II trials showed PASI-75 rates ~66-67% at week 12 versus placebo; ACCEPT trial showed superiority to etanercept for PASI-75 at week 12.PASI-75 at week 12
Targets IL-12/23 p40 subunit.
Apremilast (Otezla) evidence: PSOR-1 and PSOR-2 trials: apremilast 30 mg BID achieved ~29-33% PASI-75 vs ~5-6% for placebo at Week 16; extended-release Otezla XR added for certain pediatric/adolescent weight/age criteria in policy updates.
Aggregate step therapy and coverage criteria updates
Coverage criteria changes and step therapy for multiple psoriasis agents as recorded in history entries
Formulary and step changes over time: Policy history documents multiple events: additions/removals of preferred and non-preferred statuses for adalimumab and infliximab products, additions of biosimilars and new HCPCS codes, changes to age/weight thresholds (e.g., Tremfya weight >=40 kg; Otezla XR age >=6 and weight >=50 kg), and adjustments in number and sequencing of required prior agents for Sotyktu, Cosentyx, and others.
See product-specific sections for exact per-drug criteria.
This policy does not address intravenous (IV) and injectable therapy services for individuals receiving inpatient services. Claims for drugs administered via an IV route described in this policy must be processed through the medical benefit (not pharmacy).
All other uses of the drugs listed in this policy or in related medical policies when used in combination with each other or for conditions not outlined in this policy are considered investigational. The policy also indicates that medications must be used consistent with FDA dosing and administration information; off-label combinations or indications not specified here are not supported by this policy.
Systemic corticosteroids are generally avoided in psoriasis management because they may be associated with severe disease exacerbations both during and after treatment. This risk should be considered when selecting systemic therapies and documenting rationale for corticosteroid use, if contemplated.
This medical policy does not apply to Medicare Advantage. Member-specific coverage and benefit limits may differ; always consult the member benefit booklet or contact member services to determine coverage for a particular member.
Hospital-based outpatient infusion and injectable therapy services are considered not medically necessary when the site-of-service criteria in this policy are not met. Preferred medically necessary sites include physician offices, infusion centers, or home infusion except in specific circumstances (for example, initial 90 days of infusion or re-initiation after ≥6 months, lack of an outpatient center within 50 miles, or certain clinical risk factors).
Unless specifically stated as covered in this policy, all other uses of the drugs listed for approved conditions in this policy are considered not medically necessary. The policy requires that medications be used consistent with the drug’s FDA prescribing information and within the indications and combinations described here.
Evidence from the EFFISAYIL studies informed spesolimab’s role in generalized pustular psoriasis (GPP) flares: trial inclusion required a current moderate-to-severe GPP flare (GPPGA pustulation subscore ≥2 and ≥5% BSA) and the primary endpoint was pustulation subscore of 0 at end of Week 1. These trial-defined criteria supported the rapid-response indication for spesolimab in GPP, but do not support broader use outside those studied populations.
This medical policy is intended as a guide to evaluate medical necessity. Member contracts differ in benefits; consult the member benefit booklet or contact a customer service representative to determine whether coverage applies for a specific service or supply.
Coding and Clinical Thresholds
Notable NDC referencesNDC
NDCs starting with 00597
adalimumab-adbm (specific NDC start)
NDCs starting with 82009
adalimumab-adbm (alternate NDC start referenced)
Notable NDC references (additional history notes)NDC
NDCs starting with 00074
Humira (adalimumab) NDC start referenced in history as moved from preferred to non-preferred
Tremfya (guselkumab) weight requirementWeighs at least 40 kg
Prescriber Requirements, Prior Authorization, and Operational Notes
Note
Benefit verification reminder
Verify member benefit and eligibility before submitting prior authorization requests. Benefits vary by plan; confirm the member's pharmacy and medical benefit coverage, applicable formularies (including custom/open formularies), any High Cost/Low Value (HCLV) restrictions, and site-of-service requirements. Check for plan-specific step therapy or preferred product lists and whether the policy criteria apply to the member's plan (for example, certain Open Formulary or custom plans referenced in related policies).
Confirm whether the drug is payable under the medical benefit (IV-administered drugs must be processed via the medical benefit).
Verify whether the member’s plan requires trying preferred agent(s) first (step therapy tiers) and whether any plan-specific formulary exceptions apply (e.g., Formulary ID: 6062; Rx Plan F1).
Confirm site-of-service coverage (office, infusion center, home infusion, hospital outpatient) and any applicable distance/clinical condition exceptions (e.g., hospital outpatient medically necessary for initial 90 days or when no outpatient/home infusion within 50 miles).
Check prior authorization length limits (initial and re-authorization up to 12 months as allowed by plan).
Step Therapy
Clinical Background and Epidemiology
Psoriasis is a chronic inflammatory skin disease most commonly presenting as well-demarcated erythematous plaques with scaling. Treatment is typically stepped: topical therapies (usually corticosteroids) first-line, progressing to phototherapy, oral systemic agents (e.g., methotrexate, cyclosporine, acitretin) and biologics for individuals with moderate-to-severe disease or inadequate response to topical therapy. Systemic agents are effective but carry risks that require monitoring (for example, hepatotoxicity with methotrexate, nephrotoxicity with cyclosporine, and teratogenicity with acitretin), which influences agent selection and documentation of medical necessity.
Definitions and Disease Subtypes
inv-51: Plaque psoriasis definition/key point
DefinitionPlaque psoriasis: chronic inflammatory condition producing well-demarcated, red, scaly plaques (most common form, ~80% of cases)
Clinical impactApproximately 20–30% of people have moderate-to-severe disease; disease can substantially affect quality of life
Treatment continuumManagement ranges from topical therapies to phototherapy, oral systemic agents, and biologics depending on severity and response
inv-52: Severe pustular/exfoliative psoriasis — definition/use for emergent infliximab
Definition for emergent infliximab useSevere pustular, exfoliative, or inflammatory psoriasis may be treated emergently with infliximab products without prior first-line agent use
Applicable products
Policy Revision History
11/01/22policy_created
New policy approved October 11, 2022 and effective November 1, 2022—moved multiple psoriasis agents from Policy 5.01.550 to Policy 5.01.629 and added topical agents and spesolimab coverage.
02/01/23coverage_update
Added biosimilar Amjevita (adalimumab-atto) with identical coverage criteria to Humira and included Amjevita as a prerequisite medication for several biologics; added Amjevita to HCPCS J3590.
Key ActionObtain prior authorization per drug-specific coverage criteria; initial approvals may be up to 12 months and reauthorization up to 12 months contingent on continued clinical response.
Some agents require failure/intolerance to 2 specified agents or to listed biologics per step tier.
Step therapy biologic trials: Has had inadequate response or intolerance to specified prior biologic or targeted agents as listed for the requested agent (examples include etanercept, adalimumab biosimilars/brands, apremilast or Otezla XR, risankizumab, deucravacitinib, ustekinumab family, ixekizumab, guselkumab).agent-specific list; may require 1, 2, or ALL of listed agents depending on tier
Some TNF inhibitors and IL-23/12 agents have specific 'inadequate response to ALL' requirements or different counts per tier.
Prescriber: Medication is being prescribed by or in consultation with a dermatologist.prescriber specialty documented
Applies broadly across agent groups.
Emergent use exception: Infliximab products may be considered medically necessary as emergent treatment for severe pustular, exfoliative, or inflammatory psoriasis without prior use or failure/intolerance of a first-line agent.clinical emergent presentation
Applies to infliximab as stated.
Has had an inadequate response or intolerance to ALL or specified adalimumab biosimilars/agents depending on the specific TNF agent requested (agent-specific requirements; some require failure of multiple adalimumab formulations).
agent-specific (may require failure of multiple adalimumab formulations)
Some TNF agents require failure of multiple adalimumab products.
Responders without additional flares were eligible for a 5-year open-label extension with spesolimab SC; no long-term results are provided in this extract.
response and no additional flare
Escape treatment during Week 1 was considered nonresponse in trial operations.
PASI-75 at Week 16
Guselkumab (Tremfya) evidence: VOYAGE trials demonstrated superior PASI-75/90 and IGA 0/1 responses versus adalimumab with high response rates (e.g., PASI-90 up to ~73%); policy updated to include weight >=40 kg for Tremfya eligibility.PASI and IGA endpoints
Bimekizumab (Bimzelx) evidence: Phase 3 BE VIVID/READY/SURE trials enrolled adults with BSA >=10%, IGA >=3, PASI >=12 and showed superiority versus placebo and active comparators; common AEs included upper respiratory infections and injection site reactions.PASI/IGA/BSA thresholds in trials
Otezla (apremilast) weight criterionWeighs at least 20 kg and aged 6 years or older
inv-30: Age for site-of-service review
Site-of-service age thresholdSite-of-service medical necessity review applies to individuals aged 13 years and older
Definition of site-of-serviceSite of service = location where drug is administered (hospital outpatient, infusion center, physician's office, or at home)
RationalePediatric physiology and specialized infusion needs justify limiting site-of-service review to >13 years
inv-31: Body Surface Area (BSA) — policy definition and exceptions
Policy BSA definition>= 10% BSA is the common disease-severity threshold used to define moderate-to-severe plaque psoriasis for many biologics
Exceptions to BSA requirementApproval may be granted with <10% BSA for extensive recalcitrant facial disease, pustular involvement of hands/feet, or genital disease affecting function
Agent-specific wordingIndividual agent sections restate the >=10% BSA threshold or allow the listed exceptions (see per-agent criteria)
Follow a stepwise treatment progression for psoriasis and related indications: begin with topical therapies, progress to phototherapy or traditional systemic agents when topicals fail or disease is extensive, and consider biologics after inadequate response/intolerance to prior therapies. Document trials, responses, and intolerances to support step therapy requirements. For biologic initiation, ensure required prior systemic/phototherapy trials are met unless an exception (e.g., emergent severe pustular/exfoliative psoriasis) applies.
Phototherapy may be used when topicals fail or disease is too extensive for topicals; note availability and patient access (home units possible under DME benefit).
Systemic agents require monitoring and have toxicity considerations; document reasons biologics are being considered (e.g., inadequate response, intolerance, contraindication to systemics/phototherapy).
Biologics often require documented prior trials of specific preferred agents per step therapy tiers; exceptions allowed for emergent severe pustular/exfoliative/inflammatory psoriasis or other listed criteria.
Documentation Required
Required medical record documentation
Prescribers must document clinical rationale and prior treatment history in the medical record submitted for review. Include office visit notes with diagnosis, relevant history, physical exam, medication history, dates and duration of prior therapies, reason for discontinuation (nonresponse or intolerance), and any specialist consultation (e.g., dermatologist). Maintain documentation for re-authorization showing continued clinical benefit.
Include documentation of trials and failures/intolerances to required agents per step therapy tiers (e.g., preferred infliximab products tried before non-preferred).
For site-of-service exceptions (e.g., hospital outpatient for first 90 days, CRS criteria, lack of outpatient/home infusion within 50 miles), include clinical justification and distance/access details as applicable.
Chart notes should demonstrate positive clinical response for continuation and re-authorization requests (approval intervals up to 12 months).
Prior Authorization
Prior authorization and approval length
Prior authorization is required for listed agents and site-of-service review applies to certain IV-administered drugs (e.g., infliximab products). Requests should specify intended site of service and include supporting clinical documentation. Authorization approvals are generally up to 12 months; non-formulary exceptions may also be approved up to 12 months per policy.
All drugs in the policy: initial authorization up to 12 months; re-authorizations up to 12 months when criteria met.
IV-administered agents must be billed under the medical benefit — claims billed as pharmacy may be denied.
Site-of-service review applies to Avsola, Inflectra, and other infliximab agents listed — specify if administration is planned in office, infusion center, home infusion, or hospital outpatient.
Non-formulary exception approvals and site-of-service exceptions may be time-limited (refer to plan-specific guidance).
Denial Risk
Denial triggers and prescriber documentation requirement
Be aware of denial triggers and prescriber requirements: failure to meet documented step therapy, missing dermatologist involvement when required, site-of-service mismatches, or submitting IV drugs under the pharmacy benefit can result in denial. Ensure prescriber (or consulting specialist) attestation is included when required by the drug-specific criteria.
Denial risk if IV-administered drugs are billed via the pharmacy benefit rather than the medical benefit.
Denial risk if step therapy requirements or prescriber/consultation requirements (e.g., dermatologist) are not documented.
Site-of-service denials if criteria for hospital outpatient, home infusion, or lack of local outpatient infusion access are not met.
Applies to Avsola, Inflectra, Remicade, Renflexis, and Janssen unbranded infliximab
ContextEmergent use contrasts with stable plaque psoriasis where prior systemic therapy trials are required
inv-53: Moderate to severe plaque psoriasis (BSA threshold notes)
Moderate-to-severe threshold>= 10% BSA commonly used to define moderate-to-severe plaque psoriasis for biologic coverage
Localized severe disease noteLocalized areas (palmar-plantar, facial, genital) may be considered severe and qualify despite low total BSA
Policy consistencyMultiple agent-specific criteria repeat the >=10% BSA threshold with stated exceptions
inv-54: Site-of-service definition and age limitation for review
Site-of-service definitionLocation where the drug is administered (hospital outpatient, infusion center, physician's office, or at home)
Age limitation for site-of-service reviewSite-of-service medical necessity review is limited to individuals aged 13 years and older
Preferred medically necessary sitesPhysician's office, infusion center, or home infusion are preferred medically necessary sites; hospital outpatient has specific limited medically necessary uses (e.g., first 90 days)
inv-55: Plaque psoriasis — short descriptor
Short descriptorPlaque psoriasis: common chronic form characterized by red, scaly plaques; often managed with stepwise escalation from topicals to biologics
Prevalence noteAccounts for about 80% of psoriasis cases
Severity impactModerate-to-severe disease affects quality of life and may require systemic or biologic therapy
inv-56: Generalized pustular psoriasis (GPP) — definition and severity
GPP definitionGeneralized pustular psoriasis (GPP): sterile pustules on non-acral skin; can be multisystem and life-threatening
PrevalenceGPP is rare (global prevalence ~1.76 per million); pustular psoriasis makes up ~1% of psoriasis cases
Clinical severityMay present with systemic inflammation, fever, and requires urgent/emergent management in severe flares
inv-57: Palmoplantar pustulosis (PPP) — definition and clinical note
PPP definitionPalmoplantar pustulosis (PPP): persistent sterile pustules on the palms and soles, chronic and relapsing; may be distinct from or related to other pustular forms
Clinical notePPP can be painful and debilitating despite limited total BSA involvement; trial evidence for some biologics is limited or negative
Evidence cautionSpesolimab did not show efficacy in PPP trial (no difference in PPPASI-50 at Week 16) per referenced studies
inv-58: Key drugs and trials referenced (pivotal trials and prescribing info)
Prescribing information sourcesMultiple prescribing information documents cited (e.g., Tremfya PI, Cosentyx PI, Siliq PI) to support agent-specific criteria
Pivotal trials citedVOYAGE (guselkumab), EFFISAYIL 1 (spesolimab), PSOR trials (apremilast), BE VIVID/READY/SURE (bimekizumab) among others referenced in evidence summaries and references
Added new HCPCS code J1747 and made minor Sotyktu criteria update (approved June 13, 2023).
09/01/23coverage_and_formulary_update
Effective September 1, 2023: added Humira biosimilars as non-preferred products; updated Cosentyx step requirement and adjusted infliximab preferred/non-preferred placements effective January 1, 2024 following provider notification.
02/01/24coverage_update
Added coverage for Bimzelx (bimekizumab-bkzx) and added Bimzelx to HCPCS J3590 (approved January 9, 2024).
07/01/24formulary_update
Added and adjusted multiple adalimumab biosimilars' preferred status and updated non-preferred adalimumab coverage to require trial of all preferred adalimumab products (approved June–July 2024).
03/01/25formulary_and_reauth_update
Effective July 1, 2025 after 90-day notification: updated Humira (AbbVie) from preferred to non-preferred; clarified non-formulary exception approvals up to 12 months and other site-of-service exceptions; re-authorization duration updated to 12 months (May 1, 2025).
08/01/25hcpcs_addition
Added HCPCS code J2327 for Skyrizi (approved July 7, 2025).
10/01/25coverage_update
Removed Idacio (adalimumab-aacf) from policy and added coverage for Starjemza (ustekinumab-hmny); added Starjemza to J3590 (effective October 1, 2025).
01/01/26formulary_replacement_clarification
Clarified applicability of Section 2 to certain plans and removed reference to a Preferred formulary (approved December 8, 2025).
03/01/26coverage_update
Added coverage criteria for Otezla XR (apremilast extended release) for individuals aged ≥6 years and weighing ≥50 kg and updated Tremfya (guselkumab) coverage to include individuals weighing at least 40 kg (approved February 10, 2026).
06/01/26formulary_and_product_updatesLatest
Interim review approved May 12, 2026: added ustekinumab-aauz as non-preferred; removed coverage criteria for discontinued Yuflyma (adalimumab-aaty); updated multiple adalimumab and Simlandi product preferred statuses and adjusted preferred alternatives for several biologics.
03/01/26coverage_added
Added coverage criteria for Otezla XR (apremilast extended release) for treatment of psoriasis in individuals aged 6 years and older and weighing at least 50 kg; also added Otezla XR as a preferred alternative for several biologics.
03/01/26coverage_revised
Updated coverage criteria for Tremfya (guselkumab) to include individuals weighing at least 40 kg (approved February 10, 2026).
06/01/26coverage_and_product_removalLatest
Interim review approved May 12, 2026: removed coverage criteria for Yuflyma (adalimumab-aaty) as the product has been discontinued and updated preferred alternatives lists for multiple agents.
07/01/25hcpcs_and_formulary_additions
Added coverage criteria and HCPCS entries for multiple ustekinumab products (Imuldosa, Steqeyma, Yesintek, Wezlana, Pyzchiva, Selarsdi, and related codes) and made formulary updates effective July 1, 2025 following a 90-day provider notification.
08/01/25hcpcs_added
Added HCPCS code J2327 for Skyrizi (approved July 7, 2025) and noted other HCPCS additions missed during prior updates.
03/01/26hcpcs_and_prior_auth_updates
Added multiple HCPCS codes and updated prior authorization/administration code listings over time (including additions to J3590 and other Q-codes) and updated re-authorization durations and site-of-service review rules (history entries through March 1, 2026).
06/01/26hcpcs_and_formulary_changesLatest
Interim review approved May 12, 2026: added Q9999 (ustekinumab-aauz) as non-preferred and other HCPCS/formulary adjustments; updated many adalimumab-related HCPCS listings and moved multiple adalimumab products between preferred and non-preferred statuses.