Opzelura
Prior authorization form and clinical criteria for coverage of topical ruxolitinib (Opzelura) through AvMed specialty pharmacy, including initial and reauthorization requirements, quantity limits, age limits, prescriber specialty, concomitant therapy exclusions, prior therapy trials, and documentation requirements.
No material clinical or coverage changes — current document is a prior authorization/step-edit form with criteria and documentation requirements.
Coverage Summary
Coverage stance: covered_with_criteria — topical ruxolitinib (Opzelura) is covered when all form criteria are met and required documentation is provided. Scope: prior authorization form and clinical criteria for specialty pharmacy dispensing through AvMed (provided by Proprium Rx) covering initial and reauthorization requirements, prescriber specialty, age limits, prior therapy trials, concomitant therapy exclusions, and documentation requirements. Specialty pharmacy dispensing: Medication is provided by Specialty Pharmacy - Proprium Rx. Quantity and other thresholds: quantity limit 1 tube (60 grams) per 28 days; age thresholds: ≥ 2 years for general eczema/dermatitis use and ≥ 12 years for vitiligo; Body Surface Area thresholds: initial eczema/general BSA ≤ 20% (member will NOT be applying to more than 20% BSA) and vitiligo BSA ≤ 10% (provider attests area impacted does NOT exceed 10% BSA).
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