Siliq (brodalumab) — United Healthcare

Preferred products

• preferred adalimumab products
• Cimzia (certolizumab)
• Cosentyx (secukinumab)
• Enbrel (etanercept)
• Skyrizi (risankizumab)
• Sotyktu (deucravacitinib)
• preferred ustekinumab products
• Tremfya (guselkumab)

Initial criteria

• Submission of medical records (chart notes, laboratory values, prescription claims history) documenting all of the following:
• Diagnosis of chronic moderate to severe plaque psoriasis
• AND One of the following:
• i. All of the following:
• 1. Body surface area involvement ≥ 3%, or palmoplantar, facial, genital involvement, or severe scalp psoriasis
• AND 2. History of failure to one of the following topical therapies, unless contraindicated or clinically significant adverse effects are experienced (document drug, date, and duration of trial): Corticosteroids (e.g., betamethasone, clobetasol, desonide) OR Vitamin D analogs (e.g., calcitriol, calcipotriene) OR Tazarotene OR Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) OR Anthralin OR Coal tar
• AND 3. History of failure to a 3‑month trial of methotrexate at maximally indicated dose, unless contraindicated or clinically significant adverse effects are experienced (document drug, date, and duration of trial) [For Connecticut, Kentucky, and Mississippi business only, a 30‑day trial required]
• OR ii. Patient has been previously treated with a targeted immunomodulator FDA‑approved for the treatment of plaque psoriasis as documented by claims history or submission of medical records (document drug, date, and duration of therapy) [e.g., Cimzia (certolizumab), adalimumab, Otezla (apremilast), Skyrizi (risankizumab), ustekinumab, Tremfya (guselkumab), Enbrel (etanercept)]
• AND History of failure, contraindication, or intolerance to three of the following preferred products (document drug, date, and duration of trial): one of the preferred adalimumab products, Cimzia (certolizumab), Cosentyx (secukinumab), Enbrel (etanercept), Skyrizi (risankizumab), Sotyktu (deucravacitinib), one of the preferred ustekinumab products, Tremfya (guselkumab)
• AND Patient is not receiving Siliq in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Tremfya (guselkumab), Cosentyx (secukinumab), Taltz (ixekizumab), Ilumya (tildrakizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]
• AND Prescribed by or in consultation with a dermatologist

Approval duration

12 months