Diagnosis: Skin/Plaque Psoriasis.
Treatment: Pharmacy/Prescription Drugs/Taltz.
The health plan denied the requested exception for a prescription drug because it did not meet the plan's criteria.
The health plan's determination is upheld.

The patient is a male with psoriasis. The patient has tried and failed topical agents such as 0.05% augmented Betamethasone Dipropionate cream, 0.1% Tacrolimus ointment, and 0.1% Triamcinolone Acetonide cream, Taclonex Scalp, and Olux-E. The patient has tried and failed Humira, Stelara, and Ilumya, but has had good improvement on Cosentyx, but it did not clear his psoriasis, according to the clinic records.

The health plan's determination of Taltz is upheld.

The patient has no documented treatment failure with, or true medical contraindication to, either Otezla, Cimzia, Skyrizi, or Tremfya. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition, as is the requested Taltz.
Modern dermatology literature [2-5] supports the use of the health plan-covered and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with this particular history of systemic psoriasis therapy previously utilized and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. There is documentation of improvement while on Cosentyx, but the failure of this medication, which has a very similar level of efficacy and mechanism of action as the requested Taltz, to clear this patient's psoriasis suggests that this patient (who is starting the lower/monthly maintenance dosing of Taltz) has significant risk of treatment failure while on the maintenance dose of Taltz.
Taltz appears to being used out of convenience. Therefore, as per current medical standards of care, Taltz is neither likely to be more effective than formulary alternatives, or have less adverse effects than formulary alternatives.