CurrentUnitedHealthcarePolicy N/A

Bimzelx (bimekizumab-bkzx) prior authorization

Prior authorization and reauthorization criteria for Bimzelx (bimekizumab-bkzx) for UnitedHealthcare members, covering multiple indications (plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and hidradenitis suppurativa). Applies to providers requesting coverage for the medication.

Policy Summary

PayerUnitedHealthcare

PolicyBimzelx (bimekizumab-bkzx) prior authorization

Policy CodePolicy N/A

Change TypeAdded coverage for additional indicationsbackground updated

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests; approvals granted for 12 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis.

Added criteria for hidradenitis suppurativa.

Updated background and reference information for Bimzelx.

5indications listed for coverage

12authorization duration (months)

Prior Authprogram type

1/2025P&T approval

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Coverage Criteria for Bimzelx

Initial Therapy - Plaque Psoriasis

Covered when ALL of the following are met for moderate to severe plaque psoriasis:

Plaque psoriasis initial authorization: (1) Diagnosis of moderate to severe plaque psoriasis; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Reauthorization - Plaque Psoriasis

Reauthorization covered when ALL of the following are met for plaque psoriasis:

Plaque psoriasis reauthorization: (1) Documentation of positive clinical response to Bimzelx therapy; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Initial Therapy - Psoriatic Arthritis

Covered when ALL of the following are met for active psoriatic arthritis:

Psoriatic arthritis initial authorization: (1) Diagnosis of active psoriatic arthritis; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Reauthorization - Psoriatic Arthritis

Reauthorization covered when ALL of the following are met for psoriatic arthritis:

Psoriatic arthritis reauthorization: (1) Documentation of positive clinical response to Bimzelx therapy; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Initial Therapy - Ankylosing Spondylitis

Covered when ALL of the following are met for active ankylosing spondylitis:

Ankylosing spondylitis initial authorization: (1) Diagnosis of active ankylosing spondylitis; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Reauthorization - Ankylosing Spondylitis

Reauthorization covered when ALL of the following are met for ankylosing spondylitis:

Ankylosing spondylitis reauthorization: (1) Documentation of positive clinical response to Bimzelx therapy; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Initial Therapy - Non-radiographic axial spondyloarthritis

Covered when ALL of the following are met for non-radiographic axial spondyloarthritis:

nr-axSpA initial authorization: (1) Diagnosis of non-radiographic axial spondyloarthritis; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Reauthorization - Non-radiographic axial spondyloarthritis

Reauthorization covered when ALL of the following are met for non-radiographic axial spondyloarthritis:

nr-axSpA reauthorization: (1) Documentation of positive clinical response to Bimzelx therapy; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Initial Therapy - Hidradenitis Suppurativa

Covered when ALL of the following are met for moderate to severe hidradenitis suppurativa:

Hidradenitis suppurativa initial authorization: (1) Diagnosis of moderate to severe hidradenitis suppurativa; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Reauthorization - Hidradenitis Suppurativa

Reauthorization covered when ALL of the following are met for hidradenitis suppurativa:

Hidradenitis suppurativa reauthorization: (1) Documentation of positive clinical response to Bimzelx therapy; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

A previous notation of exclusion was removed per the Change Control history and is no longer part of this policy. No other explicit exclusions are listed in the document; coverage is governed by the indication‑specific criteria for which Bimzelx is approved (see Coverage Criteria sections for each indication).

Provider Requirements and Utilization Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for Bimzelx. When criteria are met, authorization will be issued for 12 months.

Authorization duration: 12 months
Prior authorization applies to initial and reauthorization requests when coverage criteria are satisfied

Documentation Required

Reauthorization Documentation Required

Reauthorization requests must include documentation demonstrating a positive clinical response to Bimzelx therapy; providers should document treatment benefit to support continued coverage.

Required documentation: evidence of positive clinical response for continuation of therapy
Reauthorization denial may occur if positive response is not documented

Initial Authorization Requirements

Initial Authorization

Initial authorization requires diagnosis of the covered indication and no concomitant targeted immunomodulator therapy.

Initial Authorization - indication-specific: (1) Diagnosis of the specific covered indication; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Reauthorization / Continuation Requirements

Reauthorization

Reauthorization requires documented positive clinical response and absence of concomitant targeted immunomodulator therapy.

Continuation/Reauthorization: (1) Documentation of positive clinical response to Bimzelx therapy; AND (2) Patient is not receiving Bimzelx in combination with another targeted immunomodulator (examples listed).

Authorization will be issued for 12 months.

Step Therapy and Quantity Limits

Utilization rule	Details
Supply limits and/or step therapy may be in place	UnitedHealthcare may impose quantity/supply limits and/or step therapy requirements for Bimzelx; specific limits and step edits vary by program or therapeutic class.
Automated approval based on prior claims/medication history	Initial or reauthorization approvals may be issued automatically based on previous claim or medication history without additional documentation when program rules are met.
Automated approval based on diagnosis codes (ICD-10) or claim logic	Approvals may be granted using diagnosis codes or claim logic; use of automated approval and re-approval processes varies by program or therapeutic class.

Background on Bimzelx

Bimzelx (bimekizumab‑bkzx) is a humanized interleukin‑17A and interleukin‑17F antagonist approved for multiple adult inflammatory conditions. The policy provides prior authorization criteria for the drug’s labeled indications, including moderate to severe plaque psoriasis, active psoriatic arthritis, active ankylosing spondylitis, active non‑radiographic axial spondyloarthritis with objective signs of inflammation, and moderate to severe hidradenitis suppurativa. The package insert referenced in the policy is dated November 2024.

Drug Definition

Bimzelx (bimekizumab-bkzx) — key facts

Drug nameBimzelx (bimekizumab-bkzx)

Mechanism of actionHumanized interleukin-17A and IL-17F antagonist

Indications coveredModerate to severe plaque psoriasis (adults who are candidates for systemic therapy or phototherapy); active psoriatic arthritis; active non-radiographic axial spondyloarthritis with objective signs of inflammation; active ankylosing spondylitis; moderate to severe hidradenitis suppurativa

ReferenceBimzelx [package insert]. UCB, Inc.; November 2024

Policy effective date / change notePolicy effective 2025-04-01; change control history notes added indications and updated background/reference (see Change Control)

Change Control / Revision History

2025-01-01material additionLatest

Added coverage criteria for hidradenitis suppurativa to the prior authorization policy for Bimzelx.

2024-10material change

Removed a previous notation of exclusion and added coverage criteria for psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis.

2024-04administrative