State and School Employees' Health Insurance Plan - Chronic Plaque Psoriasis

POLICY NUMBER

S.5.01.412

Avsola (infliximab-axxq)

Cimzia (certolizumab)

Ilumya (tildrakizumab-asmn)

Inflectra (infliximab-dyyb)

Infliximab

Remicade (infliximab)

Renflexis (infliximab-abda)

Please perform a search of the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting.

DESCRIPTION

Medical Covered Agents (no step therapy requirement)

¹Cimzia –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 -

• State and School Employees’ Health Insurance Plan - Anti-Rheumatic Biologicals

• State and School Employees’ Health Insurance Plan - Crohn's Disease and Ulcerative Colitis

• State and School Employees’ Health Insurance Plan - Biosimilar Medications

POLICY

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

The following medications are not covered on the State Health Plan Medical Drug Formulary:

• Avsola (infliximab-axxq)

• Renflexis (infliximab-abda) 

Initial Evaluation

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

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);

   4. The individual’s medication history indicates use of another immunomodulator agent or Otelza (apremilast) indicated for the treatment of psoriasis;

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

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

6. 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;

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

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

Length of Approval: 12 months

Renewal Evaluation

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 review 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 biologic immunomodulatory agent (i.e., TNF-inhibitor, IL-inhibitor, anti IgE antibody, etc.) or Otezla;

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 determined to be not medically necessary will also be considered not medically necessary.

POLICY EXCEPTIONS

State Health Plan (State and School Employees):  Self-administered drugs 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 self-administered drug are not covered under the medical benefit.

POLICY GUIDELINES

Medical Policy Manual coverage guidelines should not be used in lieu of the Participant's specific benefit plan language outlined in the Mississippi's State and School Employees’ Life and Health Insurance Plan.

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 Participant'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 Participant'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 Participant, his or her Provider; and

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

07/01/2023: New policy added.

02/28/2024: Updated related medical policy links.

11/01/2024: Policy updated to remove Skyrizi (risankizumab-rzaa) and Stelara (ustekinumab) from the list of drugs. Policy description updated to remove Avsola from the covered agents and to add Inflectra as a covered agent. Initial evaluation criteria updated to remove Stelara criteria. Policy statement revised to state that Avsola (infliximab-axxq) and Renflexis (infliximab-abda) are not covered. Sources updated. Code Reference section updated to add HCPCS code Q5103 to the Covered Codes table. Added HCPCS code Q5121 to the Not Covered/Non-Formulary Codes table. Removed HCPCS codes J2327 and J3358. Effective 01/01/2025.

11/15/2025: Policy statement updated to revise criteria for treatment history, body surface area involvement, combination agent use, and prescribing requirements. Sources section updated. Updated last access dates for prescribing information. 

SOURCE(S)

1. American Academy of Dermatology Association, Guidelines of Care for

   Psoriasis

   . Available at:

   https://www.aad.org/practicecenter/quality/clinical-guidelines/psoriasis

2. Avsola prescribing information. Amgen, Inc. September 2025. Last accessed October 2025.

3. Cimzia prescribing information. UCB, Inc. July 2025. Last accessed October 2025.

4. Ilumya prescribing information. Sun Pharmaceutical Industries, Inc. February 2025. Last accessed October 2025.

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

6. Infliximab prescribing information. Janssen Biotech, Inc. June 2025. Last accessed October 2025.

7. Remicade prescribing information. Janssen Biotech, Inc. June 2025. Last accessed October 2025.

8. Renflexis prescribing information. Organon LLC. January 2024. Last accessed October 2025.

9. 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.

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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