brodalumab — CareFirst (Caremark)

moderate to severe plaque psoriasis (PsO)

Initial criteria

Age ≥ 18 years
Medication is prescribed by or in consultation with a dermatologist
Member has a documented negative tuberculosis (TB) test within 12 months prior to initiating therapy if naïve to biologic or targeted synthetic drugs; if positive, further testing shows no active disease and latent disease is treated before starting therapy
Member is not using the requested medication concomitantly with any other biologic drug or targeted synthetic drug for the same indication
Authorization of 12 months may be granted for adult members who have previously received a biologic or targeted synthetic drug (e.g., Sotyktu, Otezla) indicated for moderate to severe plaque psoriasis OR when any of the following are met:
• Crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) are affected
• ≥10% of body surface area (BSA) is affected
• ≥3% of BSA is affected AND one of the following: (a) inadequate response or intolerance to phototherapy (UVB, PUVA) or systemic pharmacologic treatment with methotrexate, cyclosporine, or acitretin; OR (b) clinical reason to avoid methotrexate, cyclosporine, and acitretin

Member is an adult using the medication for moderate to severe plaque psoriasis
Member has achieved or maintained a positive clinical response as evidenced by either:
• Reduction in body surface area (BSA) affected from baseline OR
• Improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling, burning, cracking, pain)

12 months