Pharmacy Prior Authorization Criteria

Icotyde (icotrokinra)

Indications for Prior Authorization

Icotyde (icotrokinra)

• For diagnosis of Plaque Psoriasis (PsO)
  Indicated for the treatment of moderate-to-severe plaque psoriasis in adults and pediatric patients 12 years of age and older who weigh at least 40 kg who are candidates for systemic therapy or phototherapy.

Criteria

Icotyde

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Plaque Psoriasis (PsO)

• Diagnosis of moderate to severe plaque psoriasis (PsO)
AND
• One of the following [2]:
• Greater than or equal to 3% body surface area involvement
• Severe scalp psoriasis
• Palmoplantar (i.e., palms, soles), facial, or genital involvement
AND
• Both of the following:
• Patient is 12 years of age or older
• Patient weighs at least 40 kg
AND
• Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to one of the following topical therapies [3]:
• corticosteroids (e.g., betamethasone, clobetasol)
• vitamin D analogs (e.g., calcitriol, calcipotriene)
• tazarotene
• calcineurin inhibitors (e.g., tacrolimus, pimecrolimus)
AND
• Prescribed by or in consultation with a dermatologist
AND
• Both of the following:
• Minimum 3-month trial and failure, contraindication, or intolerance to THREE of the following:
• Cimzia (certolizumab pegol)
• Enbrel (etanercept)
• One formulary adalimumab product
• One formulary ustekinumab product
• Taltz (ixekizumab)
• Skyrizi (risankizumab)
• Tremfya (guselkumab)
• Otezla (apremilast)
• Sotyktu (deucravacitinib)
AND
• Minimum 3-month trial and failure, contraindication, or intolerance to Bimzelx (bimekizumab-bkzx)

Icotyde

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Plaque Psoriasis (PsO)

• Patient demonstrates positive clinical response to therapy as evidenced by ONE of the following [1-3]:
• Reduction in the body surface area (BSA) involvement from baseline
• Improvement in symptoms (e.g., pruritus, inflammation) from baseline

Icotyde

Non Formulary

Length of Approval: 6 Month(s)
For diagnosis of Plaque Psoriasis (PsO)

• Submission of medical records (e.g., chart notes) confirming a diagnosis of moderate to severe plaque psoriasis (PsO)
AND
• One of the following [2]:
• Greater than or equal to 3% body surface area involvement
• Severe scalp psoriasis
• Palmoplantar (i.e., palms, soles), facial, or genital involvement
AND
• Both of the following:
• Patient is 12 years of age or older
• Patient weighs at least 40 kg
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming a trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to one of the following topical therapies [3]:
• corticosteroids (e.g., betamethasone, clobetasol)
• vitamin D analogs (e.g., calcitriol, calcipotriene)
• tazarotene
• calcineurin inhibitors (e.g., tacrolimus, pimecrolimus)
AND
• Prescribed by or in consultation with a dermatologist
AND
• Both of the following:
• Paid claims or submission of medical records (e.g., chart notes) confirming a minimum 3-month trial and failure, contraindication, or intolerance to THREE of the following:
• Cimzia (certolizumab pegol)
• Enbrel (etanercept)
• One formulary adalimumab product
• One formulary ustekinumab product
• Taltz (ixekizumab)
• Skyrizi (risankizumab)
• Tremfya (guselkumab)
• Otezla (apremilast)
• Sotyktu (deucravacitinib)
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming a minimum 3-month trial and failure, contraindication, or intolerance to Bimzelx (bimekizumab-bkzx)

P & T Revisions

2026-03-24

References

1. Icotyde Prescribing Information. Janssen Biotech, Inc. Horsham, PA. March 2026.
2. 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;80:1029-72.
3. Elmets CA, Korman NJ, Farley Prater E, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol 2021;84:432-70.

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Revision History

• 2026-03-24: New program

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