Biologic agents for psoriasis - policy criteria

[chantell.reagan]

In May of 2008, the American Academy of Dermatology (AAD) updated guidelines for the management of psoriasis and for the first time released specific recommendations for the use of biologics in this condition. Generally the AAD recommends to use either phototherapy, photochemotherapy, systemic therapy or biologics in patients with extensive disease (BSA≥5%) and in those with limited disease who have failed topical or targeted phototherapy. Our analysis shows that at this stage, plans are more restrictive in their policies than the latest guidelines. Almost all policies require failure of at least photo/photochemotherapy in patients with extensive disease. In addition, some plans require failure of photo/photochemotherapy and systemic therapy before initiating biologics.

The following figure provides a comparative summary of the selected policies (click on the image to enlarge it).



Sources:

Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58:826-50.

Aetna. Clinical Policy Bulletin: Psoriasis:Biological therapies

Aetna. Clinical Policy Bulletin: Humira

Aetna. Clinical Policy Bulletin: Remicade

BlueCross BlueShield of Alabama. Enbrel coverage criteria

BlueCross BlueShield of Alabama. Humira coverage criteria

BlueCross BlueShield of Alabama. Raptiva coverage criteria

BlueCross BlueShield of Alabama. Amevive coverage criteria

BlueCross BlueShield of Alabama. TNF Antagonists and Other Biologics for Rheumatologic Diseases: Remicade policy

BlueCross Blue Shield of Michigan. Prior authorization/Step Therapy programs

Blue Care Network of Michigan. Medicare Prior authorization and Step Therapy program

Blue Cross and Blue Shield of Florida. Medical coverage guidelines

Cigna. Amevive Coverage Position

Cigna. Enbrel Coverage Position

Cigna. Humira Coverage Position

Cigna. Remicade Coverage Position

Cigna. Raptiva Coverage Position

Excellus BlueCross BlueShield. Psoriasis policy (Amevive, Enbrel, Raptiva)

Excellus BlueCross BlueShield. Remicade policy

The Regence Group. Enbrel policy

The Regence Group. Humira policy

The Regence Group. Remicade policy

The Regence Group. Amevive policy

The Regence Group. Raptiva policy

Wellpoint, NextRx. Enbrel policy

Wellpoint, NextRx. Humira policy

Wellpoint, NextRx. Remicade policy

Wellpoint, NextRx. Amevive policy

Wellpoint, NextRx. Raptiva policy

[chantell.reagan]

In May of 2008, the American Academy of Dermatology (AAD) also updated guidelines for the management of psoriatic arthritis (PsA). Generally, the AAD recommends using either methotrexate or TNF-blockers as first-line therapy. The guidelines also note the equivalence of all 3 TNF-blockers in the treatment of PsA. Of note, not all patients need this type of therapy. If PsA is mild, NSAIDS or intraarticular corticosteroid injections are recommended.

The following figure provides a comparative summary of the selected policies (click on the image to enlarge it).



Sources:

Blue Cross and Blue Shield of Florida. Medical coverage guidelines

The Regence Group. Enbrel policy

The Regence Group. Humira policy

The Regence Group. Remicade policy

Excellus BlueCross BlueShield. Remicade policy

BlueCross BlueShield of Alabama. Enbrel coverage criteria

BlueCross BlueShield of Alabama. Humira coverage criteria

BlueCross BlueShield of Alabama. TNF Antagonists and Other Biologics for Rheumatologic Diseases: Remicade policy

BlueCross Blue Shield of Michigan. Prior authorization/Step Therapy programs

Blue Care Network of Michigan. Medicare Prior authorization and Step Therapy program

Wellpoint, NextRx. Enbrel policy

Wellpoint, NextRx. Humira policy

Wellpoint, NextRx. Remicade policy

Aetna. Clinical Policy Bulletin: Enbrel

Aetna. Clinical Policy Bulletin: Humira

Aetna. Clinical Policy Bulletin: Remicade

Cigna. Enbrel Coverage Position

Cigna. Humira Coverage Position

Cigna. Remicade Coverage Position

[chantell.reagan]

We extended the review of biologic agents in psoriasis to include recently-approved Stelara (ustekinumab) and the withdrawal of Raptiva from the market. We analyzed 6 regional and national plans which have publicly available policies pertinent to this update. The following are our key findings:

•6 out of 6 plans failure of at least photo/photochemotherapy and/or systemic therapy
•2 out of 6 plans additionally require step therapy with a TNF inhibitor
•3 out of 6 plans have quantity limits (consistent with the labeling); 1 plan limits coverage to the two years

Sneak preview:


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Additional sources:

Blue Cross and Blue Shield of Florida. Medical coverage guidelines (see full link in the attached tabulated analysis)

The Regence Group. Enbrel policy (see full link in the attached tabulated analysis)

The Regence Group. Humira policy (see full link in the attached tabulated analysis)

The Regence Group. Remicade policy (see full link in the attached tabulated analysis)

The Regence Group. Amevive policy (see full link in the attached tabulated analysis)

The Regence Group. Stelara policy (see full link in the attached tabulated analysis) ]

BlueCross BlueShield of Alabama. Enbrel coverage criteria (see full link in the attached tabulated analysis)

BlueCross BlueShield of Alabama. Humira coverage criteria (see full link in the attached tabulated analysis)

BlueCross BlueShield of Alabama. Stelara Medicare coverage criteria (see full link in the attached tabulated analysis)

BlueCross BlueShield of Alabama. Amevive coverage criteria (see full link in the attached tabulated analysis)

BlueCross BlueShield of Alabama. Remicade Medicare coverage criteria (see full link in the attached tabulated analysis)

BlueCross Blue Shield of Michigan. Prior authorization/Step Therapy programs (see full link in the attached tabulated analysis)

Blue Care Network of Michigan. Medicare Prior authorization and Step Therapy program (see full link in the attached tabulated analysis)

Aetna. Clinical Policy Bulletin: Enbrel (see full link in the attached tabulated analysis)

Aetna. Clinical Policy Bulletin: Humira (see full link in the attached tabulated analysis)

Aetna. Clinical Policy Bulletin. Psoriasis: Biologic therapies (see full link in the attached tabulated analysis)

Aetna. Clinical Policy Bulletin: Remicade (see full link in the attached tabulated analysis)

Humana Medical Coverage Policies (see full link in the attached tabulated analysis)