Otezla XR — Cigna

Initial criteria

• Patient age ≥ 6 years
• If Otezla requested, patient weight ≥ 20 kg; OR if Otezla XR requested, patient weight ≥ 50 kg
• Patient has tried at least one traditional systemic agent for psoriasis for ≥ 3 months unless intolerant (e.g., methotrexate, cyclosporine, acitretin, or PUVA) OR patient has contraindication to methotrexate
• Medication is prescribed by or in consultation with a dermatologist

Reauthorization criteria

• Patient has been established on therapy for at least 4 months
• Patient experienced a beneficial clinical response from baseline in at least one of: estimated body surface area, erythema, induration/thickness, and/or scale
• Compared with baseline, patient experienced improvement in at least one symptom such as decreased pain, itching, and/or burning

Approval duration

initial 4 months, reauth 1 year