ModifiedPremera BluecrossPolicy N/A

Pharmacologic Treatment of Psoriatic Arthritis (drugs and site-of-service review)

Defines medical necessity criteria for pharmacologic therapies (biologics, targeted synthetic, and oral agents) for psoriatic arthritis and site-of-service review rules; applies to providers prescribing/administering these drugs and to benefit reviews for Premera members.

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic Treatment of Psoriatic Arthritis (drugs and site-of-service review)

Policy CodePolicy N/A

Change TypeMaterial updates — added products/biosimilars, age/weight revisions, new HCPCS/Q-codes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document age/weight and prior trials per product-specific medical necessity criteria before administration.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for multiple ustekinumab products and biosimilars (Imuldosa, Otulfi, Pyzchiva, Selarsdi, Starjemza, Steqeyma, Yesintek, Wezlana, and related unbranded ustekinumab entries).

Updated age requirements for several agents (Tremfya to ≥6 years; Otezla to ≥6 years; Xeljanz to ≥2 years; Simponi Aria to ≥2 years) and added weight thresholds for some agents.

Clarified that certain medical necessity criteria do not apply to members enrolled in specified custom formulary plans and referenced policy 5.01.647 for those members.

Added HCPCS/Q-codes for new biosimilars and biologic products (Q5098-Q5100, Q5103-Q5104, Q5121, Q5137-Q5145, Q9996-Q9999 and others).

Added coverage criteria for Sotyktu (deucravacitinib) for the treatment of active psoriatic arthritis.

Added multiple new ustekinumab products (Imuldosa, Otulfi, Pyzchiva, Selarsdi, Steqeyma, Yesintek, Wezlana, Starjemza) to coverage criteria and specified preferred/non-preferred status changes.

Updated age and weight requirements for several therapies (e.g., Tremfya age lowered to 6+, Simponi Aria to 2+, Otezla and Xeljanz age/weight changes).

Clarified that Site of Service Medical Necessity criteria can apply to injection drugs.

Removed reference to certain formulary sections and removed non-formulary exception reviews.

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.

Manydrugs/biosimilars listed

12max approval period (months)

3new HCPCS Q-codes

13min age for SOS review

~12+new/added products referenced

Coverage Criteria and Medical Necessity

First-line therapy (agent-specific)

Covered when ALL of the following are met, per agent-specific rules

Common requirements: Medication prescribed by or in consultation with a rheumatologist or dermatologist; patient meets age and weight requirements specified for the agentage/weight per agent

Applies across first-line agents unless otherwise noted

Adalimumab first-line (examples): Adalimumab-aaty, adalimumab-adaz, and adalimumab-adbm [NDCs starting with 00597] may be considered medically necessary when the individual is aged 18 years or older and medication is prescribed by or in consultation with a rheumatologist or dermatologist.

Infliximab biosimilars (first-line): Avsola (infliximab-axxq) and Inflectra (infliximab-dyyb) may be considered medically necessary when the individual is aged 18 years or older and medication is prescribed by or in consultation with a rheumatologist or dermatologist.

Simponi Aria and Enbrel (examples): Simponi Aria (golimumab) IV and Enbrel (etanercept) may be considered medically necessary when the individual is aged 18 years or older and medication is prescribed by or in consultation with a rheumatologist or dermatologist. (Simponi Aria has age-specific allowances noted elsewhere.)

IL-12/23 (ustekinumab) first-line examples: Stelara (ustekinumab) SC, Steqeyma (ustekinumab-stba) SC, and Yesintek (ustekinumab-kfce) SC may be considered medically necessary when age and agent-specific criteria are met and medication is prescribed by or in consultation with a rheumatologist or dermatologist.

PDE4, TYK2, JAK, and other oral agents (first-line): Otezla (apremilast) and Otezla XR, Sotyktu (deucravacitinib), Rinvoq (upadacitinib), and Xeljanz (tofacitinib) may be considered medically necessary under the age/weight and prior-failure conditions specified for each agent and when prescribed by or in consultation with a rheumatologist or dermatologist.

IL-23 inhibitors (first-line) prior-failure requirement

Covered when ALL of the following are met

IL-23 specific: Has had an inadequate response or intolerance to ALL the following: Steqeyma (ustekinumab-stba) SC AND Yesintek (ustekinumab-kfce) SC; Note: requirement applies only to individuals not previously treated with the requested therapy.prior failure of listed ustekinumab products

Requirement applies to certain IL-23 agents such as Tremfya and Skyrizi

Janus kinase inhibitors (first-line)

Covered when ALL of the following are met

Rinvoq and Xeljanz: Rinvoq (upadacitinib) and Rinvoq LQ: individual is aged 2 years or older; has had an inadequate response or intolerance to 1 or more TNF blockers; medication prescribed by or in consultation with a rheumatologist or dermatologist. Xeljanz (tofacitinib) and Xeljanz XR: individual is aged 2 years or older (some formulations) and meets prior-failure requirements as specified for each formulation; medication prescribed by or in consultation with a rheumatologist or dermatologist.prior TNF failure where specified

Specific age and prior-failure conditions differ by formulation and agent

TNF-alpha antagonists (second-line)

Covered when ALL of the following are met

TNF antagonists - second line: For listed second-line TNF agents (examples include certain adalimumab biosimilars and other TNF products), the individual is aged 18 years or older; has had an inadequate response or intolerance to ALL specified earlier agents (e.g., adalimumab-aaty, adalimumab-adaz, adalimumab-adbm with specified NDCs where applicable); and medication is being prescribed by or in consultation with a dermatologist or rheumatologist.prior failure of listed earlier adalimumab products

Some criteria exclude members in a custom Open formulary (Formulary ID: 6062; Rx Plan F1)

Infliximab agent sequencing

Covered when ALL of the following are met

Infliximab sequencing: Infliximab (Janssen-unbranded) and Remicade require documented trial and treatment failure with Avsola (infliximab-axxq) AND Inflectra (infliximab-dyyb) prior to coverage; Renflexis requires documented trial and failure with Avsola and Inflectra as well.documented trial and failure with specified infliximab biosimilars

Applies only to individuals not previously treated with requested therapy where noted

Infliximab adult coverage

Infliximab (Janssen unbranded) and Remicade may be considered medically necessary for active psoriatic arthritis when ALL of the following are met:

Infliximab adult criteria: The individual is aged 18 years or older; has had a documented trial and treatment failure with Avsola (infliximab-axxq) AND Inflectra (infliximab-dyyb); medication is being prescribed by or in consultation with a rheumatologist or dermatologist.age >= 18

Applies to specified infliximab products.

Renflexis adult coverage

Renflexis may be considered medically necessary for active psoriatic arthritis when ALL of the following are met:

Renflexis adult criteria: The individual is aged 18 years or older; has had a documented trial and treatment failure with Avsola (infliximab-axxq) AND Inflectra (infliximab-dyyb); medication is being prescribed by or in consultation with a rheumatologist or dermatologist.age >= 18

Applies to Renflexis specifically.

IL-12/23 inhibitors (ustekinumab family)

Listed IL-12/23 inhibitors (various ustekinumab products and biosimilars) may be considered medically necessary for active psoriatic arthritis when ALL of the following are met:

IL-12/23 criteria: The individual is aged 6 years or older; has had an inadequate response or intolerance to ALL the following agents: Stelara (ustekinumab) SC, Steqeyma (ustekinumab-stba) SC, Yesintek (ustekinumab-kfce) SC; medication is being prescribed by or in consultation with a dermatologist or a rheumatologist.age >= 6

Specifies prior inadequate response to listed ustekinumab products; applies to multiple ustekinumab biosimilars.

IL-17 inhibitors (second-line)

IL-17 inhibitors (example: Bimzelx) may be considered medically necessary for active psoriatic arthritis when ALL of the following are met:

Bimzelx adult criteria: The individual is aged 18 years or older; has had an inadequate response or intolerance to 1 of the following agents: Enbrel; adalimumab-aaty OR adalimumab-adaz OR adalimumab-adbm [NDCs starting with 00597]; Otezla (or Otezla XR); Skyrizi; Sotyktu; Stelara (or biosimilars); Taltz; Tremfya; and medication is prescribed by or in consultation with a dermatologist or rheumatologist.age >= 18

Lists alternative agents for trial before Bimzelx.

Cosentyx (secukinumab) coverage

Cosentyx (IV/SC) may be considered medically necessary for active psoriatic arthritis when ALL of the following are met:

Cosentyx criteria: The individual is aged 2 years or older; has had an inadequate response or intolerance to 2 of the following agents: Enbrel; adalimumab-aaty OR adalimumab-adaz OR adalimumab-adbm [NDCs starting with 00597]; Otezla (or Otezla XR); Rinvoq (or LQ); Skyrizi; Sotyktu; Stelara (or biosimilars); Taltz; Tremfya; Xeljanz (or XR); and medication is prescribed by or in consultation with a dermatologist or a rheumatologist.age >= 2

Requires failure of two alternatives.

Orencia (abatacept) coverage

Orencia IV/SC may be considered medically necessary for adults and Orencia SC for pediatric individuals with active psoriatic arthritis under specified conditions:

Orencia adult criteria: For adults: age >= 18 AND inadequate response or intolerance to 2 of the following agents: Enbrel; adalimumab-aaty OR adalimumab-adaz OR adalimumab-adbm [NDCs starting with 00597]; Otezla (or XR); Rinvoq (or LQ); Skyrizi; Sotyktu; Stelara (or biosimilars); Taltz; Tremfya; OR presence of heart failure, previously treated lymphoproliferative disorder, previous serious infection, or demyelinating disorder; medication prescribed by or in consultation with dermatologist or rheumatologist.age >= 18

Adult pathway allows either step failures or specific comorbid contraindications.

Orencia pediatric criteria: For pediatrics (SC): age >= 2 AND inadequate response or intolerance to 1 of the following agents: Enbrel; Rinvoq (or LQ); Stelara (or biosimilars); OR presence of heart failure, previously treated lymphoproliferative disorder, previous serious infection, or demyelinating disorder; medication prescribed by or in consultation with dermatologist or rheumatologist.age >= 2

Pediatric SC has lower prior therapy requirement.

Updated Medical Necessity Criteria (summary)

Policy includes medical necessity criteria that have been updated for multiple agents; specific plan/formulary distinctions apply for some products.

New product coverage: Added coverage criteria for Sotyktu (deucravacitinib) for active psoriatic arthritis and for multiple new ustekinumab products; HCPCS codes added for these products.

See prior_auth and coding sections for code lists.

Pediatric modifications: Age and weight requirements updated for Tremfya, Simponi Aria, Otezla, Xeljanz, and others as specified in policy history (examples: Tremfya age lowered to >=6 years; Simponi Aria age >=2 years; Otezla age >=6 years and weight >=20 kg; Xeljanz age >=2 years).

Exact age/weight thresholds listed in product-specific criteria.

Formulary-specific criteria: Some medical necessity criteria do not apply to certain custom Open/Preferred formulary plans; separate policy 5.01.647 may apply and providers must verify member plan.

Providers should check member plan booklet or ID card.

The Site of Service (SOS) medical necessity rules in this policy apply to medical benefit reviews and to the administration location for listed IV and injectable therapies. SOS is defined as the location where the drug is administered (for example, a hospital-based outpatient department, infusion center, physician’s office, or at home). For individuals aged 13 years and older, the site-of-service will be reviewed for medical necessity. The SOS medical necessity criteria do not apply to Alaska fully‑insured members; for those members review the infusion and injection drug medical necessity criteria and contact Customer Service for plan-specific guidance.

All uses of the agents listed in this policy that are for indications or combinations not described in this policy or in related medical policies are considered investigational. Additionally, for approved indications, any use of the drugs that does not meet the specific medical necessity criteria in this policy is considered not medically necessary. Providers must follow FDA dosing and administration guidance and submit documentation showing how the requested use meets the policy criteria.

This medical policy does not apply to Medicare Advantage. Providers and reviewers should consult the member benefit booklet or contact Customer Service to determine plan-specific benefit limitations for Medicare Advantage members and to confirm applicable coverage rules.

Hospital-based outpatient settings (for example, outpatient hospital IV infusion departments or hospital-based outpatient clinical care) are included among potential administration sites but are considered not medically necessary for infusion and injectable therapy when the site-of-service criteria in this policy are not met. The policy lists clinical exceptions where hospital outpatient administration may be appropriate (for example, unstable renal function, difficult or unstable vascular access, acute mental status changes that affect safety, severe prior hypersensitivity/anaphylaxis to related agents, or severe cytokine release syndrome meeting the policy’s grade 3–4 definition). When SOS criteria are not satisfied, services may be denied as not medically necessary.

When a drug is otherwise approved by this policy but the request does not meet the drug‑specific coverage criteria (for example, age/weight thresholds, required prior trials, or formulation-specific requirements), the use is considered not medically necessary. Documentation submitted must demonstrate that the individual meets all medical necessity requirements; absence of sufficient documentation (office visit notes, diagnosis, relevant history, physical exam, medication history) may result in denial of coverage for the requested therapy.

Policy history reflects removal of certain formulary section references and elimination of non‑formulary exception reviews. Recent updates reorganized preferred alternatives for several products and removed references to specific formulary sections (Open/Preferred/Select, Essentials, Individual/Small Group/Formulary sections) and the non‑formulary exception review process; providers should verify current formulary guidance and prior authorization requirements when requesting coverage.

Coding, HCPCS/Q-Codes, and Prescribing References

Listed biologic products (examples)mixed

Adalimumab-aaty	Adalimumab biosimilar (SC)
Adalimumab-adaz	Adalimumab biosimilar (SC)
Adalimumab-adbm	Adalimumab (NDCs starting with 00597) (SC)
Avsola (infliximab-axxq)	Infliximab biosimilar (IV)
Inflectra (infliximab-dyyb)	Infliximab biosimilar (IV)

Oral small-molecule agentsmixed

Rinvoq (upadacitinib)	Oral Janus kinase inhibitor
Xeljanz (tofacitinib)	Oral Janus kinase inhibitor
Otezla (apremilast)	Oral PDE4 inhibitor
Sotyktu (deucravacitinib)	Oral TYK2 inhibitor

IL pathway inhibitorsmixed

Stelara (ustekinumab)	IL-12/23 inhibitor (SC)
Tremfya (guselkumab)	IL-23 inhibitor (SC)
Skyrizi (risankizumab-rzaa)	IL-23 inhibitor (SC)
Taltz (ixekizumab)	IL-17 inhibitor (SC)

Covered HCPCS/J-codes and unclassified biologicsHCPCSCovered

J0129	Injection, abatacept (Orencia), 10 mg
J0139	Injection, adalimumab (Humira), 1 mg
J0717	Injection, certolizumab pegol (Cimzia), 1 mg
J1438	Injection, etanercept (Enbrel), 25mg
J1602	Injection, golimumab (Simponi Aria), 1 mg, for intravenous use
J1628	Injection, guselkumab (Tremfya), 1 mg
J1745	Injection, infliximab, excludes biosimilar (Remicade or Janssen unbranded), 10mg
J3247	Injection, secukinumab, intravenous, (Cosentyx) 1 mg
J3357	Injection, ustekinumab, subcutaneous injection (Stelera), 1mg
J3590	Unclassified biologics (used to report listed unbranded/biosimilar products)

Q-code biosimilars and product-specific HCPCSHCPCSCovered

Q5098	Injection, ustekinumab-srlf (Imuldosa), biosimilar, 1 mg
Q5099	Injection, ustekinumab-stba (Steqeyma), biosimilar, 1 mg
Q5100	Injection, ustekinumab-kfce (Yesintek), biosimilar, 1 mg
Q5103	Injection, infliximab-dyyb, biosimilar (Inflectra), 10 mg
Q5104	Injection, infliximab-abda, biosimilar (Renflexis), 10 mg
Q5121	Injection, infliximab-axxq, biosimilar (Avsola), 10 mg
Q5137	Injection, ustekinumab-auub, subcutaneous injection (Wezlana), biosimilar, 1 mg
Q5138	Injection, ustekinumab-auub, intravenous (Wezlana), biosimilar, 1 mg
Q5140	Injection, adalimumab-fkjp (Hulio), biosimilar, 1 mg
Q5141	Injection, adalimumab-aaty (Yuflyma), biosimilar, 1 mg

1–10 of 18

1/2

HCPCS Q-codes added/updatedHCPCS

Q9999	HCPCS code Q9999 (added)
Q5137	HCPCS code Q5137 for Wezlana
Q5138	HCPCS code Q5138 for Wezlana
Q9996	HCPCS code Q9996 for Steqeyma
Q9998	HCPCS code Q9998 for Steqeyma
Q5098	HCPCS code Q5098 for Imuldosa
Q5099	HCPCS code Q5099 for Otulfi
Q5100	HCPCS code Q5100 for Yesinek

Referenced Prescribing Informationmixed

N/A	Prescribing information references for listed drugs (Simlandi, Cimzia, Bimzelx, Simponi Aria, Taltz, Steqeyma, Yesintek, Tremfya, Skyrizi, Rinvoq, Xeljanz, Sotyktu).

Minimum weight for pediatric dosing

Tremfya (guselkumab)Minimum pediatric weight: ≥40 kg

Otezla (apremilast)Minimum pediatric weight: ≥20 kg

Otezla XR (apremilast extended‑release)Minimum pediatric weight: ≥50 kg

Age/weight thresholds — policy-level limits

General site-of-service age ruleSite-of-service medical necessity review applies to individuals aged ≥13 years

Prior Authorization, Step Therapy, and Documentation Requirements

Prior Authorization

Prior authorization and site‑of‑service review

Prior authorization (PA) and site‑of‑service (SOS) review apply to many listed agents. Providers must obtain prior authorization before administration of the drugs listed in this policy and are responsible for confirming whether the request is subject to SOS review (medical-benefit reviews only). SOS criteria apply to IV and certain injectable administrations; SOS review does not apply to Alaska fully‑insured members per policy. Contact Customer Service for plan‑specific applicability.

PA required prior to administration for all drugs listed in this policy.
SOS Medical Necessity criteria apply only to medical benefit reviews and to IV/injectable administrations for ages 13 and older unless otherwise noted.
Alaska fully‑insured members: SOS criteria do NOT apply.

Prior Authorization

Site‑of‑service prior authorization

Site‑of‑service prior authorization is required when SOS review applies. Requests for the listed HCPCS/J and new Q‑codes (including Q5098, Q5099, Q5100, Q5137, Q5138, Q9996, Q9998, Q9999) will be reviewed for appropriate site‑of‑service and medical necessity.

Background and Scope

Psoriatic arthritis (PsA) is an inflammatory spondyloarthropathy associated with psoriasis, characterized by peripheral and axial joint inflammation, dactylitis, enthesitis, and skin plaques. Early and appropriate pharmacologic treatment is important to prevent progressive joint damage. Therapeutic options addressed in this policy include biologic agents (TNF inhibitors, IL‑17, IL‑12/23, IL‑23 inhibitors), targeted small molecules (JAK inhibitors, TYK2 inhibitors), and oral agents (PDE4 inhibitors). Drug‑specific age and weight thresholds and step‑therapy sequencing are applied to determine medical necessity and appropriate site‑of‑service for infusion agents; prescribed therapies generally must be initiated or managed by or in consultation with a rheumatologist or dermatologist.

Definitions and Key Terms

Site of service (SOS) — definition of administration locations

DefinitionSite of service (SOS) is the location where the drug is administered (hospital‑based outpatient, infusion center, physician's office, or home).

Medically preferred sitesPhysician's office, infusion center, or home infusion are preferred medically necessary sites for specified drugs

Hospital outpatient useHospital-based outpatient setting may be medically necessary for the initial course or re‑initiation after ≥6 months, or when no outpatient/home infusion option exists within 50 miles, or when clinical risk factors exist

Cytokine release syndrome (CRS) grade 3 or 4 — clinical definition and thresholds

Core clinical criteriaCRS grade 3 or 4 is evidenced by ALL of: temperature ≥38 °C; hypotension requiring ≥1 vasopressors; and hypoxia requiring high‑flow oxygen delivery or positive pressure ventilation

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic Treatment of Psoriatic Arthritis (drugs and site-of-service review)

Policy CodePolicy N/A

Change TypeMaterial updates — added products/biosimilars, age/weight revisions, new HCPCS/Q-codes

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and document age/weight and prior trials per product-specific medical necessity criteria before administration.

SourceLink

On This Page

Tremfya (guselkumab)

Age eligibility: ≥6 years; weight threshold: ≥40 kg

Simponi Aria (golimumab)Age eligibility: ≥2 years

Xeljanz (tofacitinib)Age eligibility updated to ≥2 years for some formulations

Age/weight thresholds — examples

Tremfya (guselkumab)Covered for individuals aged ≥6 years

Simponi Aria (golimumab)Covered for individuals aged ≥2 years

Otezla (apremilast)Covered for individuals aged ≥6 years who weigh ≥20 kg

Xeljanz (tofacitinib)Covered for individuals aged ≥2 years for specified formulations

SOS review and PA required for listed IV agents (e.g., Avsola, Inflectra, Remicade, Renflexis, Infliximab (Janssen), Simponi Aria, Orencia, Cosentyx IV) and selected SC/other products as specified in the policy.
New/added HCPCS Q‑codes and Q9999 are included in the SOS/PA review.

Prior Authorization

Prior authorization required for listed products

Prior authorization is required for the listed products; failure to obtain PA may result in denial. The policy includes updated PA criteria that encompass newly listed products, biosimilars, and associated HCPCS/Q‑codes.

All drugs named in the policy are subject to PA and may be approved for up to 12 months when criteria are met.
Recent additions to the policy (e.g., multiple ustekinumab and infliximab biosimilars, Wezlana, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Starjemza, Steqeyma) are covered only when their specific coverage criteria are satisfied.

Denial Risk

Site‑of‑service noncompliance may lead to denial

If SOS criteria are not met, the requested site may be deemed not medically necessary and the claim can be denied. Providers should select the most appropriate, safe, and cost‑effective site of service consistent with the policy's medically necessary site list.

Medically necessary sites include physician office, infusion center, and home infusion when supported by criteria.
Hospital‑based outpatient is medically necessary for initial/first 90 days of therapy or re‑initiation after ≥6 months, or when no outpatient/home infusion options exist within 50 miles, or when the patient has specified high‑risk clinical conditions.

Denial Risk

Missing required trials for infliximab agents

Requests for infliximab agents (including branded and biosimilars) may be denied if required prior trials are missing. Documentation must show prior trials and inadequate response/intolerance to specified infliximab alternatives where the policy requires them.

Infliximab (Janssen unbranded) and Remicade require documented trial and treatment failure with Avsola (infliximab‑axxq) AND Inflectra (infliximab‑dyyb) for individuals not previously treated.
Renflexis requires documented trial and failure with Avsola and Inflectra as well.
Absence of these documented trials may result in denial.

Documentation Required

Documentation deficiencies trigger denial

Requests lacking required documentation may be denied. The medical record must clearly demonstrate that all policy criteria are met; absence of office notes, diagnosis, or prior treatment history is a common trigger for denial.

Denials likely when chart notes do not include diagnosis, relevant history, physical evaluation, medication history, or documentation of prior trials/intolerances.
All uses must follow FDA dosing and administration; off‑label combinations or conditions not in the policy are investigational or not medically necessary.

Denial Risk

Coverage adherence risk

Members and providers risk noncoverage if updated criteria are not followed or preferred alternatives are not used when required. Adherence to the policy's step therapy, trial, and SOS requirements is necessary to reduce coverage risk.

Policy revisions (effective dates noted in History) change preferred/non‑preferred status and required trials — verify current criteria before requesting services.
Failure to follow updated step therapy or to trial preferred products (e.g., changes in adalimumab or infliximab preferred status) may result in denial or noncoverage.

Documentation Required

Required documentation for PA and re‑authorization

Medical records submitted for review must include office visit notes with diagnosis, relevant history, physical exam, medication history, and documentation of prior therapies/trials and responses. Chart documentation should support length of therapy and ongoing positive clinical response for re‑authorization.

Include office visit notes with diagnosis, relevant history, physical evaluation, and medication history.
Document prior treatment trials, dates, reasons for discontinuation, and evidence of inadequate response or intolerance.
For re‑authorization, provide evidence of continued clinical benefit and adherence to dosing schedules.

Note

Member benefit verification required

Providers must verify member benefits and plan‑specific limits prior to submitting PA requests. Some custom formularies or plan types (e.g., Open, Preferred, Metallic, Essentials, HCLV list) have alternate criteria or exclusions; check policy 5.01.647 for custom formulary details when indicated.

Check member benefit booklet or ID card to confirm whether the policy criteria apply to the member's plan (e.g., Open formulary exceptions).
Contact Customer Service for questions about plan‑specific coverage, limits, or SOS applicability.
Certain formulary plans have different coverage rules or exceptions — review the History and related policy references for plan‑specific guidance.

Step Therapy

Step therapy requirements

Step therapy applies as outlined in the policy: agents are organized into first‑ and later‑line classes and specific step requirements must be met prior to approval. Where step therapy requires documented failure or intolerance to first‑line therapies, providers must supply that evidence.

Step therapy tiers define first‑line versus second‑line agents (e.g., TNF‑α antagonists, IL‑17, IL‑12/23, IL‑23, JAK inhibitors, PDE‑4 inhibitors).
Providers must document trials of required first‑line agents and reasons for failure/intolerance before requesting higher‑tier therapies.
Formulary and plan‑specific exceptions (Open, Metallic, Essentials) may alter step requirements.

Step Therapy

Step therapy and required prior trials (including ustekinumab)

When step therapy requires prior trials, submit documented trial dates, agent names, dosing, duration, and rationale for failure/intolerance. For ustekinumab (Stelara and biosimilars), some criteria now require trials with specific biosimilars/non‑preferred ustekinumab products prior to coverage of certain agents.

Several IL‑23 and IL‑12/23 agents (e.g., Tremfya, Skyrizi, Janus kinase inhibitors) require inadequate response/intolerance to Steqeyma (ustekinumab‑stba) AND Yesintek (ustekinumab‑kfce) for individuals not previously treated with the requested therapy.
Second‑line ustekinumab class agents (including multiple branded and unbranded ustekinumab products) require prior failure/intolerance to Stelara, Steqeyma, and Yesintek per the policy list.
Only provide trial documentation for individuals not previously treated with the requested therapy when the policy note specifies.

Grade 3–4 CRS meets criteria for inpatient admission

Examples of respiratory supportHigh‑flow nasal cannula, face mask, non‑rebreather, Venturi mask, CPAP, BiPAP, intubation, or mechanical ventilation

Psoriatic arthritis (PsA) — disease definition and characterization

DefinitionPsoriatic arthritis (PsA) is an inflammatory spondyloarthropathy associated with psoriasis, characterized by peripheral and spinal inflammation, joint destruction, dactylitis, enthesitis, and skin plaques

Clinical courseMajority of individuals develop a chronic progressive disease without effective treatment

Treatment approachPharmacologic therapy combined with physical rehabilitation and early initiation of therapy to avoid joint damage

Site of service (for administration) — location and policy limits for administration

Site locations listedHospital outpatient setting, infusion center, physician's office, or home infusion

Hospital outpatient limitsHospital-based outpatient setting is considered medically necessary for the first 90 days for initial course or re‑initiation after ≥6 months, or when no alternative within 50 miles or significant clinical risk exists

Not medically necessary conditionHospital outpatient sites are considered not medically necessary when site‑of‑service criteria are not met

HCPCS Q-codes — definition and note about new Q-codes for multiple agents

DefinitionHCPCS Q‑codes are temporary codes used to identify certain biologic products and biosimilars

New Q‑codes addedMultiple new Q‑codes were added for ustekinumab products and other biologics (examples: Q5098, Q5099, Q5100, Q5137, Q5138, Q9996, Q9998, Q9999)

Use noteQ‑codes identify specific biosimilars and product‑specific HCPCS entries included in the policy coding tables