Diagnosis: Skin Disorders - Psoriasis.
Treatment: Pharmacy/Prescription Drugs.

The health plan denied the Taltz. The denial is upheld.

The patient is an adult male with moderate to severe psoriasis (45% body surface area involvement). The patient has tried and failed topical steroids and the biologic agent Stelara. The health plan has denied the Stelara as not medically necessary.

The health plan's determination is upheld.

The patient's health plan covers Humira, Tremfya, Cimzia, Skyrizi, and Cosentyx [1], which are all appropriate for this patient's particular clinical scenario. They are not contraindicated or likely to cause an adverse reaction by or physical or mental harm to the patient. Modern dermatology literature [2-5] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with relatively little history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Taltz is not medically necessary.

The health plan-preferred alternative biologic agents are all appropriate and anticipated to benefit this patient's psoriasis, based on the patient's clinical history and scenario. The patient's past treatment and health coverage history does not show treatment failure or medical likelihood of either treatment failure or contraindication, of the health plan-covered and preferred alternative biologic medications.

The patient is not stable on Taltz after multiple failures on alternative systemic therapies and has not been on it so long that discontinuation of Taltz would pose any significant health problems for this patient.

The patient's health plan-preferred and covered biologic alternatives (Humira, Tremfya, Cimzia, Skyrizi, and Cosentyx) are all appropriate for this patient with moderate to severe psoriasis, who has failed only topical medications and Stelara. These agents are all easily-adhered to with minimal side effects compared to the requested Taltz and are likely to improve the patient's psoriasis and any associated quality of life issues.