Diagnosis: Plaque psoriasis.
Treatment: Taltz autoinjector (three pack) 80mg/ml auto inject.
The insurer denied the Formulary Exception for Taltz autoinjector (three pack) 80mg/ml auto injct.
The denial is upheld.

This is a man with psoriasis affecting 40% body surface area (BSA) for whom Taltz is requested. He is currently on Cosentyx and Clobetasol and failing the treatment. He has failed Humira in the past.

No, the health plan should not cover the proposed formulary exception for Taltz because the plan requires documented contraindications, intolerance or treatment and failure with formulary medications prior to approving a formulary exception. The patient is a candidate for systemic therapy (topical therapies are inappropriate as monotherapy for severe psoriasis). The available formulary alternatives that may be appropriate include Otezla, Stelara and Tremfya. The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first line treatments such as topical corticosteroids and calcipotriene followed by typical second line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, cyclosporine) and biologics. The patient has no documented contraindications to the use of the preferred medications.