Apremilast (Otezla®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:
  • Psoriatic Arthritis
  • Plaque Psoriasis

Otezla® is a preferred agent for the treatment of the following indication(s) when all criteria below are met for specific indication(s):

  • Psoriatic Arthritis
  • Plaque Psoriasis
Patients must meet the following criteria for the following indications (as confirmed by medical records documentation):

Psoriatic Arthritis

  • Diagnosis of active psoriatic arthritis confirmed by specialist chart note documentation, AND
  • Prescribed by or in collaboration with a rheumatologist or dermatologist, AND
  • Inadequate response, intolerance, or contraindication to one or more oral DMARDs [e.g., Methotrexate, Leflunomide, Sulfasalazine, Azathioprine, Cyclosporine], OR has a medical reason why Methotrexate, Leflunomide, and Sulfasalazine, cannot be used

Plaque Psoriasis

  • Diagnosis of chronic moderate to severe plaque psoriasis (psoriasis affects 10% or more of the body, or psoriasis involves hands, feet, head/neck or genitalia) confirmed by specialist chart note documentation, AND
  • Prescribed by or in collaboration with a dermatologist or rheumatologist, AND
  • Patient has tried and failed topical therapy (e.g., Calcipotriene, Tazarotene, topical steroids), AND
  • Documented failure or clinically significant adverse effects to one of the following therapies alone or in combination, unless contraindicated:
    • Methotrexate (doses up to 15-20 mg per week), OR 
    • If Methotrexate is contraindicated: Cyclosporine, Acitretin, or a trial with PUVA or UVB for at least 3 months unless intolerant

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • All non-FDA approved uses not listed in the approved indications
Dosing:
  • Titrate to recommended dose of 30 mg PO BID according to the following schedule:
  • Day 1:  10mg PO AM
  • Day 2:  10mg PO AM and PM
  • Day 3:  10mg PO AM and 20 mg PO PM
  • Day 4:  20mg PO AM and PM
  • Day 5:  20mg PO AM and 30 mg PO PM
  • Day 6 and thereafter:  30 mg PO BID
Approval:
  • Initial approval 4 months to assess patient's response
  • Continuation: 1 year with specialist chart notes documenting a clinical response to therapy

Last review date: July 1, 2020

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