Medical Policy

Effective Date:12/01/2016 Title:Taltz (Ixekizumab)
Revision Date:01/01/2020 Document:BI522:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

A.   Taltz (Ixekizumab) requires prior authorization.

B.   Taltz is used to treat psoriasis, psoriatic arthritis, and ankylosing spondylitis.

Taltz is a specialty drug covered under the pharmacy benefit.
Medical Statement

Taltz (Ixekizumab) is considered medically necessary for patients meeting the following conditions:

1)    Patient is 18 years of age or older  AND

2)    Has a diagnosis of active moderate to severe chronic plaque psoriasis (L40.0) and is a candidate for systemic therapy or phototherapy  AND

3)    Patient has one of the following criteria:

a.    Patient has at least 10% of body surface area (BSA) affected by plaque psoriasis OR

b.    Patient has at least 5% BSA affected by plaque psoriasis and there is involvement of sensitive areas (i.e. hands, feet, face or genitals) OR

c.    Patient has a Psoriasis Area and Severity Index (PASI) score of 10 or more AND

4)    Member has a history of failure for at least a 3 month trial of, contraindication, or intolerance to ALL of the following:

a.    Topical therapy with corticosteroids, Vitamin D analogs (e.g. calcitriol, caclipotriene), calcineurin inhibitor (e.g. tacrolimus, pimecrolimus), or salicylic acid combination product AND

b.    Phototherapy of at least 3 months duration with narrow-band UVB (in the office or at home)used alone or in combination with topical or systemic therapy (See BI 029 for additional information regarding UV light therapy) This requirement may be waived in any of the following situations: a) history or presence of melanoma or other skin cancer, lupus erythematosus, or xeroderma pigmentosum, b) psoriasis involving areas around the eye where eye protection may cause blockage of phototherapy to affected area,c) documented systemic disease involving the joints (meeting specific criteria for psoriatic arthritis), or d) very sever plaque thickness or scaling (4 on a scale of 0 to 4) AND

c.    Systemic therapy of at least 3 months with methotrexate or other non-biologic DMARD. This requirement may be waived in any of the following situations: a) member has chronic hepatic disease, b) member has acquired immunodeficiency syndrome (AIDS), c) member is pregnant or breast-feeding, or d) member has anemia, neutropenia, or thrombocytopenia.   

5)    History of failure, contraindication, or intolerance to one of the following:

a.    Humira

b.    Stelara

c.    Tremfya

d.    Cimzia

e.    Skyrizi

 

6)    Taltz will not be used concomitantly with other biologic DMARDs (e.g. Humira, Remicade, or Xeljanz) AND

7)    Patient has been tested for TB infection AND

8)    Latent TB infection has been ruled out or is being treated per guidelines

 

Taltz is also considered medically necessary for members who meet the following criteria:

1)    Diagnosis of active psoriatic arthritis AND

2)       Greater than three (3) swollen and tender joints AND

3)    Have tried and failed at least one (1) non-biologic DMARD (e.g. methotrexate, cyclosporine, sulfasalazine, leflunomide) or has a contraindication to DMARDs AND

4)    Have tried/failed, intolerant to, or has a contraindication one of the following:

Humira, Cimzia, Stelara, or Simponi

Talts is considered medically necessary for members who meet the following criteria:

1)    Member is 18 years of age or older AND

2)    Diagnosis of ankylosing spondylitis AND

Member has a history of failure, contraindication, or intolerance to one (1) of Humira, Cimzia, or Simponi.
Limits

As a specialty drug, Taltz is limited to a maximum 30 day supply per fill.

Reference

1)    Taltz Prescribing Information.  Eli Lily and Company. Indianapolis, IN.  March 2016.

2)    Clinical Pharmacology.  Accessed online September 12, 2016.

3)    Menter A, Gottlieb A, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. J Am Acad Dermatol 2008; 58:826-50.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.