biologic immunomodulator agents — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Has tried and had an inadequate response to ONE conventional agent (acitretin, anthralin, calcipotriene, calcitriol, coal tar products, cyclosporine, methotrexate, pimecrolimus, PUVA, tacrolimus, tazarotene, topical corticosteroids) after at least a 3-month duration OR has intolerance/hypersensitivity
• FDA labeled contraindication to ALL conventional agents used in PS OR
• Severe active PS (e.g., >10% BSA, select locations, etc.) OR
• Concomitant severe psoriatic arthritis OR
• Medication history indicates use of another biologic immunomodulator agent or Otezla FDA labeled or supported for PS