Otezla Prior Authorization Criteria - Medicare Part D

Initial Evaluation

Otezla will be approved when BOTH of the following are met:

1. ONE of the following:
   1. BOTH of the following
      1. The patient has ONE of the following diagnoses:
         1. Plaque psoriasis OR
         2. Active psoriatic arthritis AND
      2. ONE of the following:
         1. There is evidence of a claim that the patient is currently being treated with the requested medication within the past 90 days OR
         2. The prescriber states the patient is currently being treated with the requested medication AND provided clinical justification to support that the patient is at risk if therapy is changed OR
         3. The patient’s medication history indicates use of a biologic immunomodulator medication for the same FDA labeled indication OR
         4. The patient has tried and had an inadequate response to at least ONE conventional prerequisite medication for the requested indication OR
         5. The patient has an intolerance or hypersensitivity to at least ONE conventional prerequisite medication for the requested indication OR
         6. The patient has an FDA labeled contraindication to at least ONE conventional prerequisite medication for the requested indication OR
   2. The patient has a diagnosis of oral ulcers associated with Behcet’s disease (BD) AND
2. The requested dose is within FDA labeled dosing for the requested indication

Length of approval: 12 months

Renewal Evaluation

Otezla will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria AND
2. The patient has ONE of the following diagnoses:
   1. Plaque psoriasis OR
   2. Active psoriatic arthritis OR
   3. Oral ulcers associated with Behcet’s disease (BD) AND
3. The patient has had clinical benefit with the requested medication (i.e., slowing of disease progression or decrease in symptom severity and/or frequency) AND
4. The requested dose is within FDA labeled dosing for the requested indication

Length of approval: 12 months