Diagnosis: Plaque Psoriasis.
Treatment: Formulary exception for Taltz autoinjector 80mg/ml AUTO INJCT, Pre-service.
The insurer denied the Formulary exception for Taltz autoinjector 80mg/ml AUTO INJCT, Pre-service.
The denial is upheld.

The patient is a woman. She has had psoriasis since she was a teenager. The psoriasis affects her scalp, nails, and sensitive areas. There is a family history of psoriasis. She has no relevant co-morbidities. She has tried and failed Stelara and Skyrizi. Topical medications include Tazorac and clobetasol. She started Taltz through a co-pay program in mid-March and is seeing positive results. This is a request for Taltz injections.

No, the health plan should not cover the Formulary exception for Taltz.
The patient has tried and failed Stelara and Skyrizi.

Per the health plan's formulary preferences, the patient must try all formulary medications before a non-formulary, such as Taltz is approved. Formulary medications include Humira, Otezla, Tremfya, Enbrel, Cosentyx, and Cimzia. They are acceptable alternatives to Taltz. Cosentyx and Taltz have a similar mechanism of action. Cosentyx is a human interleukin-17A antagonist indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy; adults with active psoriatic arthritis (PsA); adults with active ankylosing spondylitis (AS); and adults with active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation.

It is reasonable to expect that other biologic medications, such as Humira, Tremfya, Enbrel, Cosentyx, and Cimzia will be beneficial for the patient's diagnosis.