COVERED USES:

FDA Approved Indication:

Raptiva® is indicated for treatment of adults patients (18 years and older) with chronic moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

Requests for a non-FDA approved ("off-label") indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

AGE RESTRICTIONS:

Must be 18 years or older.

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Must meet the following for initial therapy:

• Have chronic moderate to severe plaque psoriasis defined as significant involvement (greater than 50%) of two of the following four areas: leg, trunk (stomach, chest, back), arms, and head. If patient has less than 50%, but involves palms, soles, head and neck, or genitalia, criteria will be met, AND
• Trial and failure or contraindication to one or more high potency topical corticosteroids, AND
• Trial and failure or contraindication of one or more oral systemic therapies, either methotrexate, acitretin, or cyclosporine.

For reauthorization, documentation must be provided showing adequate response to therapy.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization will be for up to six months. Reauthorization will be for up to one year.