Subject: Tremfya 2156-A SGM P2022
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
FDA-Approved Indications
1. Treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for
systemic therapy or phototherapy
2. Treatment of adult patients with active psoriatic arthritis
All other indications are considered experimental/investigational and not medically necessary.
II. DOCUMENTATION
Submission of the following information is necessary to initiate the prior authorization review:
A. Plaque psoriasis
1. Initial requests:
i. Chart notes or medical record documentation of affected area(s) and body surface
area (BSA) affected.
ii. Chart notes, medical record documentation, or claims history supporting previous
medications tried (if applicable), including response to therapy. If therapy is not advisable,
documentation of clinical reason to avoid therapy.
2. Continuation requests: Chart notes or medical record documentation of decreased body
surface area (BSA) affected and/or improvement in signs and symptoms.
B. Psoriatic arthritis: For continuation requests: Chart notes or medical record documentation
supporting positive clinical response.
III. CRITERIA FOR INITIAL APPROVAL
A. Moderate to severe plaque psoriasis (PsO)
1. Authorization of 12 months may be granted for members who have previously received
Otezla or a biologic indicated for the treatment of moderate to severe plaque psoriasis.
2. Authorization of 12 months may be granted for treatment of moderate to severe plaque
psoriasis in members when any of the following criteria is met:
i. Crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous
areas) are affected.
ii. At least 10% of the body surface area (BSA) is affected.
iii. At least 3% of body surface area (BSA) is affected and the member meets any of the following criteria:
a. Member has had an inadequate response or intolerance to either phototherapy (e.g., UVB,
PUVA) or pharmacologic treatment with methotrexate, cyclosporine or acitretin.
b. Member has a clinical reason to avoid pharmacologic treatment with methotrexate,
cyclosporine and acitretin (see Appendix).
B. Active psoriatic arthritis (PsA)
Authorization of 12 months may be granted for treatment of active psoriatic arthritis.
IV. CONTINUATION OF THERAPY
A. Moderate to severe plaque psoriasis (PsO)
Authorization of 12 months may be granted for all members (including new members) who are
using the requested medication for moderate to severe plaque psoriasis and who achieve or
maintain positive clinical response as evidenced by low disease activity or improvement in
signs and symptoms of the condition when any of the following is met:
1. Reduction in body surface area (BSA) affected from baseline
2. Improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling,
burning, cracking, pain)
B. Active psoriatic arthritis (PsA)
Authorization of 12 months may be granted for all members (including new members) who are
using the requested medication for active psoriatic arthritis and who achieve or maintain positive
clinical response as evidenced by low disease activity or improvement in signs and symptoms of
the condition when there is improvement in any of the following from baseline:
1. Number of swollen joints
2. Number of tender joints
3. Dactylitis
4. Enthesitis
5. Skin and/or nail involvement
V. OTHER
For all indications: Member has had a documented negative TB test (which can include a tuberculosis skin test [PPD], an interferon-release assay [IGRA], or a chest x-ray)* within 6 months of initiating therapy for persons who are naïve to biologic DMARDs or targeted synthetic DMARDs associated with an increased risk of TB.
* If the screening testing for TB is positive, there must be further testing to confirm there is no active disease. Do not administer the requested medication to members with active TB infection. If there is latent disease, TB treatment must be started before initiation of the requested medication.
For all indications: Member cannot use the requested medication concomitantly with any other biologic DMARD or targeted synthetic DMARD.
VI. DOSAGE AND ADMINISTRATION
Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.
Special Notes:
VII. APPENDIX
Examples of Clinical Reasons to Avoid Pharmacologic Treatment with Methotrexate, Cyclosporine or Acitretin
1. Clinical diagnosis of alcohol use disorder, alcoholic liver disease or other chronic liver disease
2. Breastfeeding
3. Drug interaction
4. Cannot be used due to risk of treatment-related toxicity
5. Pregnancy or currently planning pregnancy
6. Significant comorbidity prohibits use of systemic agents (examples include liver or kidney disease,
blood dyscrasias, uncontrolled hypertension)
Place of Service:
Outpatient
The above policy is based on the following references:
- Tremfya [package insert]. Horsham, PA: Janssen Biotech, Inc.; July 2020.
- Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 4: Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61:451-485.
- Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 6: Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011;65(1):137-174.
- Reich K, Armstrong, AW, Foley P, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: Results from the phase III, double-blind, placebo- and active comparator–controlled VOYAGE 2 trial. Am J Clin Dermatol. 2017;76(3):418-431.
- Blauvelt A, Papp KA, Griffiths, CEM, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: Results from the phase III, double-blinded, placebo- and active comparator-controlled VOYAGE 1 trial. Am J Clin Dermatol. 2017;76(3):405-417.
- Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029-1072.
- Tuberculosis (TB). TB risk factors. Centers for Disease Control and Prevention. Retrieved on 15 November 2021 from: https://www.cdc.gov/tb/topic/basics/risk.htm.
- Gossec L, Baraliakos X, Kerschbaumer A, et al. European League Against Rheumatism (EULAR) recommendations for themanagement of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020;79(6):700-712.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
June 26, 2022
