Otezla (apremilast) — Highmark

Psoriatic Arthritis (spinal or axial)

Initial criteria

for PsA forms: age ≥18 years OR age 6–<18 years with weight ≥20 kg
diagnosis matches indication type
prescribed by or in consultation with a rheumatologist or dermatologist
spinal/axial PsA: therapeutic failure/intolerance to ≥1 NSAID or all NSAIDs contraindicated
non-spinal PsA: therapeutic failure/intolerance to ≥1 non-biologic DMARD (e.g., methotrexate, leflunomide, sulfasalazine, cyclosporine) or all non-biologic DMARDs contraindicated
enthesitis/dactylitis PsA: therapeutic failure/intolerance to ≥1 NSAID or a local glucocorticoid injection, or all NSAIDs and local injections contraindicated
Adult Plaque Psoriasis: age ≥18 years, diagnosis of PsO (excluding L40.5), prescribed by dermatologist or rheumatologist, AND one of the following: failure/intolerance to phototherapy, failure/intolerance to ≥1 systemic therapy (e.g., methotrexate), or contraindicated to both phototherapy and systemic therapy
Pediatric Plaque Psoriasis: age 6–<18 years, weight ≥20 kg, moderate-to-severe PsO, prescribed by dermatologist or rheumatologist, AND one of the following: failure/intolerance to phototherapy, failure/intolerance to ≥1 systemic therapy, or contraindicated to both phototherapy and systemic therapy
Oral ulcers associated with Behçet’s Disease: age ≥18 years, diagnosis of oral ulcers with Behçet’s, prescribed by rheumatologist or dermatologist, AND failure/intolerance to ≥1 topical triamcinolone product for acute flares AND failure/intolerance to colchicine for prevention

Reauthorization criteria

disease stability or beneficial response to therapy