UnitedHealthcare Pharmacy
Clinical Pharmacy Programs
Program Number
Program
Medication
P&T Approval Date
Effective Date
2014 P 1129-2
Notification
Otezla® (apremilast)
5/2014, 10/2014
1/1/2015
1. Background:
Otezla is indicated for the treatment of adult patients with active psoriatic arthritis and for the
treatment of patients with moderate to severe plaque psoriasis for whom phototherapy or systemic
therapy is appropriate.
2. Coverage Criteria:
A. Psoriatic Arthritis (PsA)
1. Initial Authorization
a. Otezla will be approved based on both of the following criteria:
(1) Diagnosis of active psoriatic arthritis
-AND(2) Patient is not receiving Otezla in combination with either of the following:
(a) Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab),
Simponi (golimumab), Orencia (abatacept)]
(b) Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]
Authorization will be issued for 12 months.
2. Reauthorization
a. Otezla will be approved based on both of the following criteria:
(1) Documentation of positive clinical response to Otezla therapy
-AND(2) Patient is not receiving Otezla in combination with either of the following:
(a) Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab),
Simponi (golimumab), Orencia (abatacept)]
(b) Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]
Authorization will be issued for 24 months.
Confidential and Proprietary, © 2014 UnitedHealthcare Services, Inc.
1
B. Plaque Psoriasis
1. Initial Authorization
a. Otezla will be approved based on both of the following criteria:
(1) Diagnosis of moderate to severe plaque psoriasis for whom phototherapy or
systemic therapy is appropriate.
-AND(2) Patient is not receiving Otezla in combination with either of the following:
(a) Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab),
Simponi (golimumab), Orencia (abatacept)]
(b) Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]
Authorization will be issued for 12 months.
2. Reauthorization
a. Otezla will be approved based on both of the following criteria:
(1) Documentation of positive clinical response to Otezla therapy
-AND(2) Patient is not receiving Otezla in combination with either of the following:
(a) Biologic DMARD [e.g., Enbrel (etanercept), Humira (adalimumab),
Simponi (golimumab), Orencia (abatacept)]
(b) Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]
Authorization will be issued for 24 months.
3. Additional Clinical Rules:
Supply limits may be in place.
4. References:
1. Otezla [package insert]. Summit, NJ: Celgene Corporation; September 2014.
Program
5/2014
10/2014
Otezla (apremilast) Notification
Change Control
New program.
Added new indication for plaque psoriasis.
Confidential and Proprietary, © 2014 UnitedHealthcare Services, Inc.
2

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