ALL of the following
Documented definitive diagnosis of moderate-to-severe chronic plaque psoriasis
Form asks prescriber to indicate Yes/No
Beneficiary is 18 years of age or older
Form asks prescriber to indicate Yes/No
Beneficiary is not on another injectable biologic immunomodulator
Form asks prescriber to indicate Yes/No
Beneficiary has been considered and screened for latent tuberculosis infection
Form asks prescriber to indicate Yes/No; exemption noted for Otezla
Beneficiary has been tested with Hep B SAG and Core Ab
Form asks prescriber to indicate Yes/No
Body surface area (BSA) involvement of at least 3%>= 3%
Form asks prescriber to indicate Yes/No
Involvement of special sites
Involvement of palms causing disruption in normal daily activities and/or employment
Involvement of soles causing disruption in normal daily activities and/or employment
Involvement of head and neck causing disruption in normal daily activities and/or employment
Involvement of genitalia causing disruption in normal daily activities and/or employment
Prior therapy or contraindication
Failed to respond to, or unable to tolerate phototherapy
Failed to respond to, or unable to tolerate ONE of the following systemic medications: Soriatane (acitretin), Methotrexate, and/or Cyclosporine
Beneficiary has contraindications to phototherapy and/or the listed systemic medications
Prior biologic therapy requirement or exception
Trial and failure of Cosentyx (secukinumab), Enbrel (etanercept), or Humira (adalimumab)
Clinical reason beneficiary cannot try Cosentyx, Enbrel, or Humira
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title": "Request for Plaque Psoriasis (Adult) - Coverage Criteria"
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title_final":"Request for Plaque Psoriasis (Adult) - Coverage Criteria"
title_actual":"Request for Plaque Psoriasis (Adult) - Coverage Criteria"
title_real":"Request for Plaoriasis (Adult) - Coverage Criteria"
title_exact":"Request for Plaque Psoriasis (Adult) - Coverage Criteria"
title_correct":"Request for Plaque Psoriasis (Adult) - Coverage Criteria"
title_request":"Request for Plaque Psoriasis (Adult) - Coverage Criteria"
title_request_exact":"Request for Plaque Psoriasis (Adult) - Coverage Criteria"
ref_request_exact":"b1_0"