Chronic Plaque Psoriasis

POLICY NUMBER

L.5.01.412

Abrilada (adalimumab-afzb)                 Pyzchiva (ustekinumab-ttwe)

Amjevita (adalimumab-atto)                Remicade (infliximab)

Avsola (infliximab-axxq)                      Renflexis (infliximab-abda)

Bimzelx (bimekizumab-bkzx)               Selarsdi (ustekinumab-aekn)

Cimzia (certolizumab)                         Siliq (brodalumab)

Cosentyx (secukinumab)                     Simlandi (adalimumab-ryvk)

Cyltezo (adalimumab-adbm)                Skyrizi (risankizumab-rzaa)

Enbrel (etanercept)                             Sotyktu (deucravacitinib)

Hadlima (adalimumab-bwwd)               Stelara (ustekinumab)

Hulio (adalimumab-fkjp)                      Steqeyma (ustekinumab-stba)

Humira (adalimumab)                         Taltz (ixekizumab)

Hyrimoz (adalimumab-adaz)                Tremfya (guselkumab)

Idacio (adalimumab-aacf)                    Vtama (tapinarof)

Ilumya (tildrakizumab-asmn)               Wezlana (ustekinumab-auub)

Imuldosa (ustekinumab-srlf)

Yesintek (ustekinumab-kfce)

Inflectra (infliximab-dyyb)                    Yuflyma (adalimumab-aaty)

Infliximab                                           Yusimry (adalimumab-aqvh)

Otezla/Otezla XR (apremilast)

Otulfi (ustekinumab-aauz)

Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.

DESCRIPTION

Table 1: Pharmacy Preferred / Non-Preferred Agents

¹Refer to the Otezla Medical Policy for coverage criteria.

Table 2: Medical Covered Agents (no step therapy requirement)

²Cimzia – If the request is for self-administered Cimzia, please refer to Table 1. Placement in Table 2 is in reference to the lyophilized powder for healthcare provider administration.  Conventional Agent Prerequisites by Indication

*Table is not an all-inclusive listing of options for prerequisite therapies available.

Related medical policies -

• Anti-Rheumatic Biologicals

• Crohn's Disease and Ulcerative Colitis

• Otezla

• Hidradenitis Suppurativa (HS)

• Uveitis

• Biosimilar Medications

POLICY

Prior Authorization is required.

The use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements.

Hadlima and Simlandi are the adalimumab formulary options effective 01/01/2025.

Selarsdi, Steqeyma, and Yesintek are the ustekinumab formulary options effective 08/01/2025.

The following medications are not covered on any BCBSMS Formulary:

• Abrilada (adalimumab-afzb)

• Amjevita (adalimumab-atto)

• Avsola (infliximab-axxq)

• Bimzelx (bimekizumab-bkzx)

• Cyltezo (adalimumab-adbm)

• Hulio (adalimumab-fkjp)

• Humira (adalimumab)

• Hyrimoz (adalimumab-adaz)

• Idacio (adalimumab-aacf)

• Imuldosa (ustekinumab-srlf)

• Otulfi (ustekinumab-aauz)

• Pyzchiva (ustekinumab-ttwe)

• Renflexis (infliximab-abda)

• Sotyktu (deucravacitinib)

• Stelara (ustekinumab)

• Vtama (tapinarof)

• Wezlana (ustekinumab-auub)

• Yuflyma (adalimumab-aaty)

• Yusimry (adalimumab-aqvh)

Initial Criteria

The requested agent may be considered medically necessary when ALL of the following criteria are met:

1. ONE of the following:

   1. The individual is 18 years of age or older;

   2. The individual is 4 years of age or older and the request is for Enbrel; 

   3. The individual is 6 years of age or older and the request is for Cosentyx, formulary ustekinumab, or Taltz; OR

   4. The individual is 6 years of age or older and weighs at least 40kg, and the request is for Tremfya;

2. The individual has a diagnosis of plaque psoriasis and ONE of the following:

   1. Involvement of at least 10% total body surface area (BSA); OR  

   2. <10% BSA with involvement of sensitive areas of the body or areas that would significantly impact daily function (e.g., face, neck, hands, feet, genitals);

3. ONE of the following:

   1. The individual has failed (see definition of Failure in Policy Guidelines section) previous treatment with at least ONE of the listed conventional agents;

   2. The individual has an FDA-labeled contraindication or hypersensitivity to ALL conventional agents; 

   3. There is documentation that the individual is currently being treated with the requested agent (use of samples or vouchers/coupons is not approvable); OR

   4. The individual’s medication history indicates use of another biologic immunomodulator agent or Otelza (apremilast) indicated for the treatment of psoriasis (use of samples or vouchers/coupons is not approvable);

4. If request is for formulary ustekinumab 90mg, the individual weighs >100kg;

5. If request is for a non-preferred agent, then ONE of the following:

   1. The individual's medication history indicates trial and failure of the required number of preferred biologic agents (See Table 1: Pharmacy Preferred / Non Preferred Agents) unless there is an FDA-labeled contraindication or hypersensitivity to all of the required preferred agents; OR

   2. The request is for an FDA-labeled indication that is not covered by the preferred products;

6. The requested agent will not be used in combination with another immunomodulatory agent (i.e., TNF-inhibitor, JAK inhibitor, IL-inhibitor, anti IgE antibody, Otezla, etc);

7. The individual does not have any contraindication(s) to therapy with the requested agent;

8. The individual has been tested for latent TB when required by the prescribing information for the requested agent AND if positive, the individual has begun therapy for latent TB; 

9. The prescriber is or has consulted with a specialist in the area of the individual’s diagnosis (i.e. board certified dermatologist); AND

10. The prescribed dosage is within the program quantity limits based on FDA approved labeled dosage.

 Length of Approval: 12 months with exceptions detailed below

• Siliq - initial approval 16 weeks and requires documentation of adequate response for continued treatment for 12 months 

Renewal Criteria The requested agent may be approved for renewal when ALL of the following criteria are met:

1. The individual has been previously approved for therapy through BCBSMS PA process;

2. The individual has shown clinical improvement (i.e. slowing of disease progression or decrease in symptom severity and/or frequency);

3. The individual does not have any FDA-labeled contraindication(s) to therapy with the requested agent;

4. The individual is not currently being treated with another immunomodulatory agent (i.e., TNF-inhibitor, JAK inhibitor, IL-inhibitor, anti IgE antibody, Otezla, etc);

5. The prescribed dosage is within the program quantity limits based on FDA-approved labeled dosage.

Length of Approval: 12 months

Services related to delivery and/or administration of a medication which has not been approved through the BCBSMS PA review process will be considered not medically necessary.

POLICY EXCEPTIONS

State Health Plan (State and School Employees) Participants

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medication failure is defined as disease progression despite maximally tolerated dose (>3 consecutive months use) as appropriate for disease state being treated. Experience of common side effects of medication will not be considered medication failure for the purpose of this review.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B. appropriate with regard to standards of good medical practice; and

C. not solely for the convenience of the Member, his or her Provider; and

D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

7/20/2004: Approved by Pharmacy & Therapeutics (P&T) Committee.

8/24/2004: Alefacept (Amevive®) and Efalizumab (Raptiva®) medical policies merged with Chronic Plaque Psoriasis medical policy and archived.

9/30/2004: Code Reference section completed.

10/28/2005: Description section updated; deleted the statement "of the p75 TNF receptor" in the Etanercept definition; chart updated to include PUVB and PUVA. FDA approved indications revised; deleted dosing information, added link to Anti-Rheumatic Biologicals medical policy. Policy section updated; Accredo telephone # for Enbrel® changed from 1-866-489-1899 to 1-866-240-3373. Fax # changed from 1-866-489-1901 to 1-866-481-7762. Accredo telephone # for Raptiva® changed from 1-866-898-0136 to 1-866-240-3373. Fax # changed from 1-866-898-0136 to 1-866-481-7762. CuraScript telephone # changed from 1-888-875-8062 to 1-877-462-6211. Fax # changed from 1-888-875-8050 to 1-877-462-6234. Under Alefacept deleted step 2 about patient response to corticosteroids treatment. Added statement about Entanercept use and link to Anti-Rheumatic Biologicals medical policy. Sources updated; Raptiva® added.

11/04/2005: Code Reference section updated, the drug's brand name added to the description of codes J0215 (Amevive®), J1438 (Enbrel®) and S0162 (Raptiva®).

11/2005: Approved by Pharmacy & Therapeutics (P&T) Committee.

6/27/2006: CuraScript fax number changed to 1-866-239-5502.

8/22/2006: Coverage of Enbrel dosing addressed.

9/27/2006: Remicade® information added to policy.

2/16/2007: Fax number for Enbrel® and Remicade® changed from 1-866-481-7762 to 1-866-489-1901. Added Accredo telephone and fax number for Raptiva®.

4/24/2007: Remicade® added to drug table.

10/17/2007: Added Accredo is our preferred provider for Amevive®.

2/4/2008: Added Humira® prescribing information. J0135 added.

01/01/2009: Accredo and CuraScript preferred provider information removed. BCBSMS information added.

3/9/2008: Notice of withdrawal of Raptiva® from the market added to policy.

10/30/2009: Policy Subtitle updated to add Ustekinumab (Stelara™), and to remove Efalizumab (Raptiva®), Description Section updated with Ustekinumab (Stelara™) description, FDA indication, and identification names, Effectiveness of Treatment Table removed, and Efalizumab (Raptiva®) description removed, Policy Statement Section updated to add Ustekinumab (Stelara™) medically necessary and treatment information, Policy Sources Section updated to add Ustekinumab (Stelara™) prescribing information, Coding Section updated to add CPT4 code J3490 to Covered Codes Table to be used to code Ustekinumab (Stelara™), HCPCS code S0162 removed from Covered Codes Table.

02/28/2011: Added new HCPCS J3357 for Stelara™ to the Code Reference section.

03/31/2011: Policy statement updated to state that effective 04/01/11, new starts are only considered for Enbrel or Stelara after failed treatment with Humira.

01/09/2013: Added the following to the Policy Exceptions section: State Health Plan (State and School Employees): Prior authorization is not required for State Health Plan members. However, these biologic drugs will be reviewed for medical necessity based on medical policy guidelines.

11/15/2013: Policy reviewed; no changes to policy statement. Policy reformatted for clarity purposes.

07/29/2014: Policy statement revised to remove "Tacrolimus" from the list of criteria and add "previous" to the statement: Patient has failed previous treatment with at least 1 of the following systemic or photo therapies.

11/05/2014: Policy updated to add coverage guidelines for apremilast (Otezla®). Medically necessary policy statement updated to add apremilast (Otezla®) for patients with moderate to severe chronic plaque psoriasis. Added policy statement that Otezla® is only considered after failed treatment with Humira®. Sources section updated to add Otezla® prescribing information.

05/29/2015: Policy updated to add coverage guidelines for Secukinumab (Cosentyx™).

08/26/2015: Medical policy revised to add ICD-10 codes.

05/26/2016: Policy number L.5.01.412 added. Policy Guidelines updated to add medically necessary and investigative definitions.

10/20/2016: Policy updated to remove information regarding Alefacept (Amevive®) and to add coverage guidelines for Ixekizumab (Taltz™). For Taltz™, documentation of failed treatment with Humira® is required, and dosing is 160mg (two 80mg injections) at week 0, followed by 80mg at weeks 2, 4, 6, 8, 10, and 12, then 80mg every 4 weeks. Sources updated. Code Reference section updated to remove HCPCS code J0215.

11/01/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.

01/01/2017: Policy updated to remove Otezla® information. Added link to new Otezla® medical policy in policy description. Code Reference section updated to revise code descriptions for HCPCS codes J1745 and J3357.

03/08/2017: Policy statement revised to state that Etanercept (Enbrel®) is considered medically necessary for patients 4 years and older with moderate to severe chronic plaque psoriasis when certain criteria are met. Medically necessary criteria updated to add failed treatment with Narrow Band UVB as an indication. Criteria for Enbrel® updated to clarify adult and pediatric dosing.

04/01/2017: Policy evaluated and updated to add coverage guidelines for Inflectra®. Sources section updated.

06/26/2017: Code Reference section updated to add new HCPCS code Q9989, effective 07/01/2017.

11/14/2017: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.

12/22/2017: Code Reference section updated to add new 2018 HCPCS code J3358.

01/31/2018: Policy description updated to add information regarding Brodalumab (Siliq™), Guselkumab (Tremfya®), and Infliximab-abda (Renflexis™). Policy section updated to add coverage criteria for Infliximab-abda (Renflexis™), Brodalumab (Siliq™), and Guselkumab (Tremfya®). Sources updated.

03/05/2018: Policy description updated to add preferred/nonpreferred agents and conventional agent prerequisites for psoriasis. Policy section updated to add prior authorization criteria for initial and renewal evaluations. Sources updated. Effective 04/01/2018.

03/29/2018: Code Reference section updated to add new HCPCS codes Q5103 and Q5104, effective 04/01/2018.

05/31/2018: Deleted outdated references from Sources section and updated links.

12/19/2018: Code Reference section updated to add new HCPCS codes J1628 and Q5109, effective 01/01/2019.

03/26/2019: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added drug names to the top of the policy. Policy description updated to add statement that the conventional agent prerequisites table is not an all-inclusive listing of options for prerequisite therapies available. Policy statement for initial evaluation updated to state that the patient has failed (>3 months use) previous treatment with at least ONE of the listed conventional agents. Sources updated. Code Reference section updated to remove deleted HCPCS code Q9989.

10/01/2019: Policy description updated to add Skyrizi and Tremfya as preferred agents. Tremfya was previously listed as a non-preferred agent. Added Cimzia as a non-preferred agent. Policy statements unchanged.

10/31/2019: Policy description updated to add Ilumya as a non-preferred agent. Initial evaluation criteria updated to make the following correction: ">3 months use" changed to "≥3 months use."

02/25/2020: Policy description updated regarding the following program requirement for psoriasis: trial/failure with three preferred agents then trial/failure with Cimzia.

01/01/2021: Added Avsola (infliximab-axxq) to the top of the policy. Policy description updated regarding Pharmacy Preferred/Non-Preferred Agents and Medical Covered Agents. Policy section updated to state that the use of samples by a Member will not be considered current or stable therapy for purposes of Medical Policy review. Added statement that Renflexis (infliximab-abda) is considered not medically necessary as other formulary options exist for the treatment of chronic plaque psoriasis. Policy statement criteria updated to reference the definition of "failure" in the Policy Guidelines and to list examples of biologic immunomodulatory agents. Policy Guidelines updated to define medication failure and to change "Nervous/Mental Conditions" to "Mental Health Disorders." Code Reference section updated to move HCPCS code Q5104 from Covered to Not Medically Necessary.

01/05/2021: Policy section updated for Stelara to change the age requirement from "12 Years" to "6 years." Revised policy statement criteria to state that "If request is for Stelara 90mg, the patient weighs >100kg AND the patient has failed (had an inadequate response to) a trial of 45mg for at least 3 maintenance doses." Sources updated.

01/11/2021: Code Reference section updated to add HCPCS codes J0717, J3245, and Q5121.

10/04/2021: Policy description updated to move Siliq from a Step 2 Non-Preferred Agent to a Step 3 Non-Preferred Agent. Policy statements unchanged.

07/25/2022: Policy updated to add Infliximab. Sources updated.

09/14/2022: Policy description updated to add infliximab as a covered agent for psoriasis. Code Reference section revised to update code description for HCPCS code J1745.

11/03/2022: Policy updated to add that Vtama (tapinarof) cream is considered not medically necessary as other formulary options exist for the treatment of chronic plaque psoriasis. Added statement that services related to delivery and/or administration of a medication which has not been approved through the BCBSMS PA review process will be considered not medically necessary. Policy Guidelines updated regarding medication failure. Sources updated.

01/25/2023: Code Reference section updated to add new HCPCS code J2327, effective 01/01/2023.

02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at  https://www.dfa.ms.gov/cvs-caremark  and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.

04/26/2023: Policy updated to add Sotyktu (deucravacitinib) as not medically necessary as other formulary options exist for the treatment of chronic plaque psoriasis. Sources updated. Effective 01/10/2023.

07/01/2023: Policy description updated regarding Pharmacy Step 1 Preferred Agents, Medical Covered Agents, and related medical policies. Policy section updated to state that Abralida (adalimumab-afzb), Cyltezo (adalimumab-adbm), Hulia (adalimumab-fkjp), Hyrimoz (adalimumab-adaz), Idacio (adalimumab-aacf), Yuflyma, Yusimry (adalimumab-aqvh), Inflectra (infliximab-dyyb), Ixifi (infliximab-qbtx), and Renflexis (infliximab-abda) are considered not medically necessary as other formulary options exist for the treatment of chronic plaque psoriasis. Policy Exceptions updated regarding State Health Plan (State and School Employees) Participants. Sources updated. Code Reference section updated to move HCPCS codes Q5103 and Q5109 from Covered to Not Medically Necessary.

11/03/2023: Policy statement updated to include Sotyktu (deucravacitinib) and Vtama (tapinarof) in the not medically necessary statement. Added the generic for Yuflyma to the policy statement.

03/08/2024: Policy description updated to remove Amjevita as a Step 1 Preferred Agent for psoriasis. Policy section updated to state that Amjevita (adalimumab-atto) is considered not medically necessary as other formulary options exist for the treatment of chronic plaque psoriasis.

04/01/2024: Policy updated to add Bimzelx (bimekizumab-bkzx) as not medically necessary as other formulary options exist for the treatment of chronic plaque psoriasis. Sources updated.

05/13/2024: Policy updated to add Simlandi (adalimumab-ryvk). Policy description updated to add Simlandi as a Step 1 Preferred Agent for psoriasis. Policy statements unchanged. Sources updated.

05/31/2024: Policy updated to state that Hadlima or Simlanda are the adalimumab formulary options for new starts effective 07/01/2024.

07/12/2024: Code Reference section updated to add HCPCS codes Q5131 and Q5132 to the Not Medically Necessary Codes table.

11/01/2024: Policy description updated to remove Humira as a Step 1 preferred agent for psoriasis. Removed Avsola as a covered agent and added Inflectra. Policy section updated to revise statement to state that the use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements. Revised policy statement to state that Hadlima and Simlandi are the adalimumab formulary options effective 01/01/2025. Medically necessary criteria updated to add Cosentyx and Taltz as indications for individuals 6 years of age and older. Policy statements updated to change language from "patient" to "individual." Revised policy statement to state that the following medications are not covered on any BCBSMS Formulary: Abrilada (adalimumab-afzb), Amjevita (adalimumab-atto), Avsola (infliximab-axxq), Bimzelx (bimekizumab-bkzx), Cyltezo (adalimumab-adbm), Hulio (adalimumab-fkjp), Humira (adalimumab), Hyrimoz (adalimumab-adaz), Idacio (adalimumab-aacf), Renflexis (infliximab-abda), Sotyktu (deucravacitinib), Vtama (tapinarof), Yuflyma (adalimumab-aaty), and Yusimry (adalimumab-aqvh). Sources updated. Code Reference section updated to add HCPCS code Q5103 to the Covered Codes table. Added HCPCS codes J0135 and Q5121 to the Not Covered/Non-Formulary Codes table. Removed Ixifi (infliximab-qbtx) as it is no longer on the market. Effective 01/01/2025.

01/01/2025: Code Reference section updated to add new HCPCS codes J0139, Q5140, Q5141, Q5142, Q5143, Q5144, and Q5145.

01/23/2025: Table 1 for Pharmacy Preferred/Non-Preferred Agents updated to change "Stelara SC" to "Stelara." Policy statements unchanged.

07/01/2025: Policy updated to add Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), Selarsdi (ustekinumab-aekn), Steqeyma (ustekinumab-stba), Wezlana (ustekinumab-auub), and Yesintek (ustekinumab-kfce). Table 1 in policy description updated to add Selarsdi, Steqeyma, and Yesintek as Step 1 Preferred Agents. Added note that Stelara will no longer be covered effective 8/1/25. Policy section updated to add the following medications as not covered on any BCBSMS formulary: Otulfi (ustekinumab-aauz), Pyzchiva (ustekinumab-ttwe), and Wezlana (ustekinumab-auub). Medically necessary criteria updated to replace "Stelara" with "formulary ustekinumab." Sources updated. Code Reference section updated to add HCPCS codes Q5099, Q5100, and Q9998 to the Covered Codes table. Added HCPCS codes Q5137, Q5138, Q9996, Q9997, and Q9999 to the Not Covered/Non-Formulary Codes table.

08/01/2025: Policy description updated to remove Stelara as a Step 1 preferred agent for psoriasis. Added policy statement that Selarsdi, Steqeyma, and Yesintek are the ustekinumab formulary options effective 08/01/2025. Added Imuldosa (ustekinumab-srlf) and Stelara (ustekinumab) to the list of medications not covered on any BCBSMS Formulary. Sources updated. Code Reference section updated to add HCPCS codes J3357, J3358, and Q5098 to the Not Covered/Non-Formulary Codes table.

11/15/2025: Policy description updated to add Otezla XR to the list of Step 1 preferred agents. Added link to the Otezla medical policy for the coverage criteria for Otezla and Otezla XR. Policy statement updated to add pediatric indication for Tremfya. Updated criteria for treatment history, body surface area involvement, combination agent use, and prescribing requirements. Updated last access dates for prescribing information in Sources section. 

SOURCE(S)

1. Abrilada prescribing information. Pfizer Laboratories Div Pfizer Inc. January 2025. Last accessed September 2025.

2. Menter, Alan et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. Journal of the American Academy of Dermatology, Volume 80, Issue 4, 1029 – 1072.

3. Amjevita prescribing information. Amgen Inc. August 2024. Last accessed September 2025.

4. Avsola prescribing information. Amgen Inc. September 2025. Last accessed September 2025.

5. Bimzelx prescribing information. UCB, Inc. June 2025. Last accessed September 2025.

6. Cimzia prescribing information. UCB, Inc. July 2025. Last accessed September 2025.

7. Cosentyx prescribing information. Novartis Pharmaceuticals Corporation. August 2025. Last accessed September 2025.

8. Cyltezo prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. August 2025. Last accessed September 2025.

9. Enbrel prescribing information. Immunex Corporation. June 2025. Last accessed September 2025.

10. Hadlima prescribing information. Organon LLC. June 2024. Last accessed September 2025.

11. Hulio prescribing information. Viatris Specialty LLC. August 2023. Last accessed September 2025.

12. Humira prescribing information. AbbVie Inc. July 2025. Last accessed September 2025.

13. Hyrimoz prescribing information. Sandoz Inc. July 2025. Last accessed September 2025.

14. Idacio prescribing information. Fresenius Kabi USA, LLC. October 2024. Last accessed September 2025.

15. Ilumya prescribing information. Sun Pharmaceutical Industries, Inc. February 2025. Last accessed September 2025.

16. Imuldosa prescribing information. Accord BioPharma Inc. September 2025. Last accessed September 2025.

17. Inflectra prescribing information. Pfizer Laboratories Div Pfizer Inc. September 2025. Last accessed September 2025.

18. Infliximab prescribing information. Janssen Biotech, Inc. June 2025. Last accessed September 2025.

19. Otezla/Otezla XR prescribing information. Amgen, Inc. August 2025. Last accessed October 2025.

20. Otulfi prescribing information. Fresenius Kabi USA, LLC. October 2024. Last accessed September 2025.

21. Pyzchiva prescribing information. Cordavis Limited. August 2025. Last accessed September 2025.

22. Remicade prescribing information. Janssen Biotech, Inc. June 2025. Last accessed September 2025.

23. Renflexis prescribing information. Organon LLC. January 2024. Last accessed September 2025.

24. Selarsdi prescribing information. Teva Pharmaceuticals USA, Inc. February 2025. Last accessed September 2025.

25. Siliq prescribing information. Bausch Health US LLC. November 2024. Last accessed September 2025.

26. Simlandi prescribing information. Teva Pharmaceuticals USA, Inc. February 2025. Last accessed September 2025.

27. Skyrizi prescribing information. AbbVie Inc. September 2025. Last accessed September 2025.

28. Sotyktu prescribing information. E.R. Squibb & Sons, L.L.C. September 2022. Last accessed September 2025.

29. Stelara prescribing information. Janssen Biotech, Inc. Julye 2025. Last accessed September 2025.

30. Steqeyma prescribing information. CELLTRION USA Inc. April 2025. Last accessed September 2025.

31. Taltz prescribing information. Eli Lilly and Company. November 2024. Last accessed September 2025.

32. Tremfya prescribing information. Janssen Biotech, Inc. August 2025. Last accessed September 2025.

33. Vtama prescribing information. Organon LLC. May 2025. Last accessed September 2025.

34. Wezlana prescribing information. Optum Health Solutions (Ireland) Limited. April 2025. Last accessed September 2025.

35. Yesintek prescribing information. Biocon Biologics Inc. November 2024. Last accessed September 2025.

36. Yuflyma prescribing information. Celltrion USA, Inc. March 2025. Last accessed September 2025.

37. Yusimry prescribing information. Coherus BioSciences, Inc. May 2025. Last accessed September 2025.

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes     

Not Covered/Non-Formulary Codes

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