Beginning April 1, 2015, Harvard Pilgrim will require prior authorization for coverage of the medication Otezla (apremilast), which was approved by the FDA for the treatment of active psoriatic arthritis in adults last year. However, prior authorization will not be required for members who have filled a prescription for Otezla in the previous 6 months.
Harvard Pilgrim’s Otezla Clinical Coverage Criteria detail the requirements that must be met in order to obtain prior authorization, including:
- Patient is 18 years of age or older.
- Diagnosis of active psoriatic arthritis or moderate to severe plaque psoriasis.
- For patients with active psoriatic arthritis:
- Prescribed by (or in consultation with) a rheumatologist or dermatologist.
- Patient has tried and failed therapy with, or has a contraindication to a DMARD (disease-modifying anti-rheumatic drug) such as methotrexate, leflunomide, hydroxychloroquine, or sulfasalazine.
- For patients with moderate to severe plaque psoriasis:
- Prescribed by (or in consultation with) a dermatologist.
- Patient has tried at least one course of systemic therapy for psoriasis including (but not limited to) acitretin, azathioprine, cyclosporine, hydroxyurea, methotrexate, mycophenolate mofetil, oral methoxsalen plus UVA light (PUVA), propylthiouracil, sulfasalazine, tacrolimus, or 6-thioguanine.
- Patient has tried and failed therapy with, or has a contraindication to Humira or Enbrel.
Approvals will be valid for 12 months. Harvard Pilgrim requires the following for a prior authorization to be renewed: the medication is prescribed by or in consultation with a dermatologist or rheumatologist, the patient has been diagnosed with psoriatic arthritis or plaque psoriasis, and symptoms have improved while the patient is on Otezla therapy.
Otezla is covered on Harvard Pilgrim’s Premium formularies only at the highest tier (i.e., Tier 3 on the 3-Tier and Tier 4 on the 4-Tier) and must be obtained through Accredo. To request prior authorization, please complete the Otezla Medication Request Form and fax it to MedImpact HealthCare Systems at 888-807-6643. For more information, please refer to the Pharmacy section of Harvard Pilgrim’s provider website.