Adalimumab — United Healthcare

Initial criteria

• Diagnosis of moderate to severe chronic plaque psoriasis
• Greater than or equal to 3% body surface area involvement, palmoplantar, facial, genital involvement, or severe scalp psoriasis AND History of failure to one of the following topical therapies (unless contraindicated or clinically significant adverse effects): corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar AND History of failure to a 3 month trial of methotrexate at maximally indicated dose unless contraindicated or clinically significant adverse effects OR previously treated with targeted immunomodulator FDA-approved for plaque psoriasis OR currently on adalimumab therapy and not received manufacturer supplied sample or manufacturer sponsored program assistance
• Patient is not receiving adalimumab in combination with another targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, Orencia, ustekinumab, Skyrizi, Tremfya, Cosentyx, Taltz, Siliq, Ilumya, Xeljanz, Olumiant, Rinvoq, Otezla)
• Prescribed by or in consultation with a dermatologist

Reauthorization criteria

• Documentation of positive clinical response to adalimumab therapy
• Patient is not receiving adalimumab in combination with another targeted immunomodulator (e.g., Enbrel, Cimzia, Simponi, Orencia, ustekinumab, Skyrizi, Tremfya, Cosentyx, Taltz, Siliq, Ilumya, Xeljanz, Olumiant, Rinvoq, Otezla)

Approval duration

12 months