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The Policy VaultThe Policy Vault

Otezla (apremilast) — Blue Cross Blue Shield of Montana

FDA labeled indications including plaque psoriasis, psoriatic arthritis, Behçet’s disease or other labeled uses

Initial criteria

  • 1. The patient meets indication-specific criteria as outlined in policy sections (e.g., Behçet’s disease, plaque psoriasis, psoriatic arthritis, other labeled or compendia-supported uses)
  • 2. The patient’s age is within FDA labeling for the requested indication OR use is supported in compendia for patient’s age
  • 3. The patient will NOT use the requested agent concomitantly with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR if used in combination BOTH of the following must be met: (a) prescribing information does not limit such combination, AND (b) clinical support for use in combination is provided (submitted trials, studies, or guidelines required)
  • 4. The patient has a diagnosis of mild severity plaque psoriasis OR prescriber is a specialist in the area of diagnosis (e.g., dermatologist, rheumatologist) or has consulted with one
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent
  • 6. Compendia sources allowed: AHFS, DrugDex level 1, 2a, 2b, NCCN level 1, 2a, 2b
  • 7. Length of approval: 12 months (starter and maintenance products each 12 months if applicable)

Reauthorization criteria

  • 1. The patient has been previously approved for the requested agent through the plan’s prior authorization process
  • 2. The patient has had clinical benefit with the requested agent
  • 3. The patient will NOT use the requested agent concomitantly with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors) OR if used in combination BOTH of the following must be met: (a) prescribing information does not limit such combination, AND (b) clinical support for use in combination is provided
  • 4. The patient has a diagnosis of mild severity plaque psoriasis OR prescriber is a specialist in or has consulted a specialist in the area of diagnosis
  • 5. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months