ModifiedUnitedHealthcarePolicy 2025 P 1129-17

Pa Notification Otezla

UnitedHealthcare prior authorization/notification program for Otezla and Otezla XR (apremilast) specifying initial and reauthorization clinical criteria for psoriatic arthritis, plaque psoriasis, and Behçet's disease, plus combination therapy exclusions and administrative rules. Authorization periods and additional clinical/billing rules are included.

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Otezla

Policy CodePolicy 2025 P 1129-17

Change TypeModified (added Otezla XR; PsO wording updated)

Effective DateFeb 1, 2026

Next Review Date

Key ActionPrior authorization/notification is required for Otezla and Otezla XR; initial and reauthorization approvals require meeting the policy clinical criteria.

SourceLink

POLICY UPDATE CHANGES

Added Otezla XR to the program with same clinical criteria as Otezla.

Removed 'candidates for phototherapy or systemic therapy' from plaque psoriasis criteria.

Updated background to reflect pediatric indications for plaque psoriasis and active psoriatic arthritis.

Updated examples and not receiving in combination language to 'targeted immunomodulator' with updated examples.

3Covered Indications

12 monthsAuthorization Duration

examples listed

Concomitant therapy exclusion

Coverage Summary

UnitedHealthcare requires prior authorization/notification for Otezla and Otezla XR (apremilast). Coverage is covered with clinical criteria for active psoriatic arthritis, plaque psoriasis, and Behçet's disease (adult indications). Pediatric indications (plaque psoriasis in patients ≥6 years and ≥20 kg, and active psoriatic arthritis) are reflected in the policy background. Authorization approvals (initial and reauthorization) follow the policy clinical criteria and are issued for 12 months. The policy also includes an exclusion that patients must not receive Otezla or Otezla XR in combination with another systemic targeted immunomodulator for the same indication; examples of such agents are provided in the policy.

Initial Therapy Criteria

Psoriatic Arthritis - Initial Authorization

Otezla or Otezla XR will be approved based on both of the following criteria:

Diagnosis of active psoriatic arthritis
Combination therapy exclusion: Patient is not receiving Otezla or Otezla XR in combination with another systemic targeted immunomodulator (e.g., adalimumab, bimekizumab-bkzx (Bimzelx), certolizumab (Cimzia), secukinumab (Cosentyx), etanercept (Enbrel), abatacept (Orencia), upadacitinib (Rinvoq), golimumab (Simponi), risankizumab (Skyrizi), ixekizumab (Taltz), guselkumab (Tremfya), tofacitinib (Xeljanz/Xeljanz XR), ustekinumab) for treatment of the same indication

Plaque Psoriasis - Initial Authorization

Otezla or Otezla XR will be approved based on both of the following criteria:

Diagnosis of plaque psoriasis
Combination therapy exclusion: Patient is not receiving Otezla or Otezla XR in combination with another systemic targeted immunomodulator (e.g., adalimumab, bimekizumab-bkzx (Bimzelx), certolizumab (Cimzia), secukinumab (Cosentyx), etanercept (Enbrel), tildrakizumab (Ilumya), risankizumab (Skyrizi), brodalumab (Siliq), deucravacitinib (Sotyktu), ixekizumab (Taltz), guselkumab (Tremfya), ustekinumab) for treatment of the same indication

Behçet's Disease - Initial Authorization

Otezla or Otezla XR will be approved based on all of the following criteria:

Diagnosis of Behçet's disease
Oral ulcers: Patient has oral ulcers attributed to Behçet's disease
Combination therapy exclusion: Patient is not receiving Otezla or Otezla XR in combination with another systemic targeted immunomodulator (e.g., adalimumab, certolizumab (Cimzia), etanercept (Enbrel), baricitinib (Olumiant), abatacept (Orencia), golimumab (Simponi), tocilizumab) for treatment of the same indication

Continuation / Reauthorization Criteria

Psoriatic Arthritis - Reauthorization

Otezla or Otezla XR will be approved based on both of the following criteria:

Positive response: Documentation of positive clinical response to Otezla or Otezla XR therapy
Combination therapy exclusion: Patient is not receiving Otezla or Otezla XR in combination with another systemic targeted immunomodulator (e.g., adalimumab, bimekizumab-bkzx (Bimzelx), certolizumab (Cimzia), secukinumab (Cosentyx), etanercept (Enbrel), abatacept (Orencia), upadacitinib (Rinvoq), golimumab (Simponi), risankizumab (Skyrizi), ixekizumab (Taltz), guselkumab (Tremfya), tofacitinib (Xeljanz/Xeljanz XR), ustekinumab) for treatment of the same indication

Plaque Psoriasis - Reauthorization

Otezla or Otezla XR will be approved based on both of the following criteria:

Concomitant Therapy Exclusions

Definition: A “Systemic targeted immunomodulator” refers to biologic or targeted systemic agents (examples listed in the policy) that should not be used concomitantly with Otezla/Otezla XR for the same indication. Policy rule: the patient must not receive Otezla or Otezla XR in combination with another systemic targeted immunomodulator for treatment of the same indication. Examples of these agents are provided in the policy and listed in the policy examples/code group (e.g., adalimumab, bimekizumab-bkzx, certolizumab, secukinumab, etanercept, abatacept, upadacitinib, golimumab, risankizumab, ixekizumab, guselkumab, tofacitinib, ustekinumab, and others).

Provider Actions & Administrative Rules

Prior Authorization

Prior authorization/notification required

Prior authorization/notification is required for Otezla and Otezla XR per the UnitedHealthcare Pharmacy Clinical Pharmacy Programs; initial and reauthorization approvals require meeting the policy clinical criteria.

Documentation Required

Documentation of positive clinical response for reauthorization

For reauthorization, provider must document positive clinical response to Otezla or Otezla XR therapy.

Applicable Codes & Examples

Examples of systemic targeted immunomodulators to avoid concomitant use with Otezla/Otezla XR (informational)mixed

adalimumab	example TNF inhibitor (Humira/adalimumab)
bimekizumab-bkzx	Bimzelx
certolizumab	Cimzia
secukinumab	Cosentyx
etanercept	Enbrel
abatacept	Orencia
upadacitinib	Rinvoq
golimumab	Simponi
risankizumab	Skyrizi
ixekizumab	Taltz

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Clinical Evidence & References

P&T Approval Dates: multiple approval dates listed from 5/2014 through 11/2025, with the latest updates including 6/2025, 9/2025, and 11/2025. Reference: Otezla/Otezla XR package insert, Amgen Inc.; August 2025. Note: pediatric indications were added to the policy background in subsequent updates (changes noted in 6/2024 and 9/2025).

Background

Background: Otezla/Otezla XR (apremilast) is a PDE4 inhibitor indicated for adult patients with active psoriatic arthritis, plaque psoriasis, and oral ulcers associated with Behçet's disease. The policy background has been updated to include pediatric indications: plaque psoriasis for patients ≥6 years of age and weighing at least 20 kg, and active psoriatic arthritis. Otezla XR was added to the program with the same clinical criteria as Otezla, and the prior authorization/notification program details (initial and reauthorization criteria, combination-therapy exclusions, and administrative rules) are included in the policy.

Quick facts

Policy Number2025 P 1129-17

Effective Date2026-02-01

Last Review2025-11-01

Next Review

Authorization Duration12 months

Revision History

2014-05program_creation

Program created (new prior authorization program for Otezla).

2014-10coverage_change

Added new indication for plaque psoriasis.

2015-02administrative

No change to coverage criteria; minor reformatting and updated clinical rules/background.

Policy Summary

PayerUnitedHealthcare

PolicyPa Notification Otezla

Policy CodePolicy 2025 P 1129-17

Change TypeModified (added Otezla XR; PsO wording updated)

Effective DateFeb 1, 2026

Next Review Date

Key ActionPrior authorization/notification is required for Otezla and Otezla XR; initial and reauthorization approvals require meeting the policy clinical criteria.

SourceLink

On This Page

Positive response: Documentation of positive clinical response to Otezla or Otezla XR therapy

Combination therapy exclusion: Patient is not receiving Otezla or Otezla XR in combination with another systemic targeted immunomodulator (e.g., adalimumab, bimekizumab-bkzx (Bimzelx), certolizumab (Cimzia), secukinumab (Cosentyx), etanercept (Enbrel), tildrakizumab (Ilumya), risankizumab (Skyrizi), brodalumab (Siliq), deucravacitinib (Sotyktu), ixekizumab (Taltz), guselkumab (Tremfya), ustekinumab) for treatment of the same indication

Behçet's Disease - Reauthorization

Otezla or Otezla XR will be approved based on both of the following criteria:

Positive response: Documentation of positive clinical response to Otezla or Otezla XR therapy
Combination therapy exclusion: Patient is not receiving Otezla or Otezla XR in combination with another systemic targeted immunomodulator (e.g., adalimumab, certolizumab (Cimzia), etanercept (Enbrel), baricitinib (Olumiant), abatacept (Orencia), golimumab (Simponi), tocilizumab) for treatment of the same indication

Billing Rule

Authorization duration

Authorizations will be issued for 12 months.

Documentation Required

Combination therapy exclusion

Provider must ensure patient is not receiving Otezla/Otezla XR in combination with another systemic targeted immunomodulator for the same indication; examples of agents are provided in the policy.

Denial Risk

Automated approvals may be used

UnitedHealthcare may approve initial and reauthorization requests based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic; automated processes vary by program.

2016-03review

No change to coverage criteria; updated reference.

2017-03annual_review

Annual review with no changes to clinical criteria.

2018-03annual_review

Annual review with no changes to clinical criteria; updated reference.

2018-07administrative

Administrative change to include Oxford effective date.

2019-03annual_review

Annual review with no change to coverage criteria.

2020-03coverage_change

Updated background and criteria to include coverage for new indication for oral ulcers associated with Behçet's disease.

2021-03policy_update

Annual review with no change to clinical criteria; reauthorization changed from 24 to 12 months and reference updated.

2022-02coverage_update

Updated background and coverage criteria with expanded plaque psoriasis indication; reference updated.

2023-02annual_review

Annual review: updated listed examples (Humira to adalimumab) and added Rinvoq; added state mandate footnote.

2023-07non_material_revision

Updated 'not receiving in combination' language to 'targeted immunomodulator' and updated example agents. Coverage intent unchanged.

2024-06non_material_revision

Updated background to reflect new pediatric indication for plaque psoriasis; reference updated. Coverage intent unchanged.

2025-06non_material_revision

Annual review with no change to clinical criteria; updated 'not used in combination' examples with no change to clinical intent.

2025-09non_material_revision

Updated background to reflect new pediatric indication for active psoriatic arthritis; reference updated.

2025-11material_additionLatest

Added Otezla XR to the program with the same clinical criteria as Otezla; removed 'candidates for phototherapy or systemic therapy' wording from the plaque psoriasis criteria. (Material change)