CurrentAvMedPolicy N/A

Topical Rosacea Drugs Prior Authorization / Step-Edit Criteria

Defines prior authorization and step-edit requirements for topical rosacea medications (brimonidine, oxymetazoline, ivermectin) for AvMed members; applies to prescribing providers requesting coverage.

Policy Summary

PayerAvMed

PolicyTopical Rosacea Drugs Prior Authorization / Step-Edit Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization with documentation of age, diagnosis, impact on quality of life, and trials/failures of two listed therapies (>=30 days each) within the last 6 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3drugs listed on form

2therapy failures required

30min trial (days)

6 molookback period

Coverage Criteria — Topical Rosacea Agents

Brimonidine (Mirvaso) and Oxymetazoline (Rhofade) — Initial approval criteria

Covered when ALL of the following are met

Age and impact: Member is 18 years of age or older AND member's quality of life has been impacted

Diagnosis: Member has ONE of: persistent (non-transient) facial erythema (subtype erythematotelangiectatic rosacea) OR papulopustular lesions with persistent (non-transient) facial erythema

Prior therapy failures: Member has tried and failed at least 30 days of therapy with two (2) of the following within the last 6 months: azelaic acid gel 15%; oral doxycycline hyclate; oral minocycline; oral tetracycline; metronidazole cream 0.75%; metronidazole 0.75% gel; metronidazole 1% gel; sodium sulfacetamide sulfur 10%/5%; topical retinoids (e.g., adapalene, tretinoin) (topical retinoids require prior authorization)2 therapies failed; each trial >= 30 days

Policy Summary

PayerAvMed

PolicyTopical Rosacea Drugs Prior Authorization / Step-Edit Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization with documentation of age, diagnosis, impact on quality of life, and trials/failures of two listed therapies (>=30 days each) within the last 6 months.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Ivermectin (Soolantra) — Initial approval criteria

Covered when ALL of the following are met

Diagnosis: Member must have papulopustular rosacea with inflammatory lesions

Submit chart notes documenting treatment failure; prior therapies may be verified through pharmacy paid claims

Required Prior Therapy for Initial Approval

Required prior therapy options

Initial approval requires documented trials and failures of listed alternatives

Prior therapies: Trial and failure of at least two (2) of: azelaic acid gel 15%; oral doxycycline hyclate; oral minocycline; oral tetracycline; metronidazole cream 0.75%; metronidazole 0.75% gel; metronidazole 1% gel; sodium sulfacetamide sulfur 10%/5%; topical retinoids (e.g., adapalene, tretinoin)2 therapies failed; each trial >= 30 days within past 6 months

Submit chart notes documenting treatment failure; prior therapies may be verified through pharmacy paid claims; topical retinoids require prior authorization

Step Therapy Requirements and Evidence

Prior therapy (must try and fail 2 therapies)	Required trial duration / lookback	Documentation accepted
azelaic acid gel 15%	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Oral doxycycline hyclate	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Oral minocycline	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Oral tetracycline	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Metronidazole cream 0.75%	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Metronidazole 0.75% gel	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Metronidazole 1% gel	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Sodium sulfacetamide sulfur 10%/5%	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims
Topical retinoids (e.g., adapalene, tretinoin) — requires prior authorization	>= 30 days within the last 6 months	Chart notes or pharmacy paid claims

Provider Requirements, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for topical brimonidine (Mirvaso), oxymetazoline (Rhofade), and ivermectin (Soolantra). Authorization may be delayed or denied if the request form is incomplete, incorrect, illegible, or missing required information (including prescriber signature and accurate contact information).

Fax completed form to 1-305-671-0200.
Prescribing physician must sign and print name (preprinted stamps not valid).
Incomplete, incorrect, or illegible information may delay the authorization process.

Documentation Required

Required Supporting Documentation

All documentation supporting each checked clinical criterion must be provided. This includes chart notes documenting treatment failures, pharmacy claims, lab results, diagnostics, and any other relevant clinical records. Failure to submit supporting documentation for each checked item may result in denial.

Provide chart notes documenting treatment failures or intolerance for prior therapies.
Pharmacy paid claims may be used to verify previous therapies; if unavailable, submit clinic notes.
Include diagnosis, ICD code (if applicable), dosing schedule, length of therapy, weight (if applicable) and date weight obtained.

Step Therapy

Step Therapy Requirements

Step therapy requires trial and failure of at least two (2) listed therapies for a minimum of 30 days each within the last 6 months prior to approval. Submit chart notes documenting the trial and reason for failure or intolerance for each agent.

Trials must be within the past 6 months.
Acceptable prior therapies include: azelaic acid gel 15%, oral doxycycline hyclate, oral minocycline, oral tetracycline, metronidazole cream 0.75%, metronidazole 0.75% gel, metronidazole 1% gel, sodium sulfacetamide-sulfur 10%/5%, topical retinoids (e.g., adapalene, tretinoin) (*topical retinoids require prior authorization).
Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Denial Risk

Incomplete Documentation Risks Denial

Authorization may be delayed or denied if documentation is incomplete, incorrect, illegible, or missing required items. Ensure all clinical criteria boxes are addressed and supporting documentation is attached to avoid processing delays.

Missing prescriber signature or contact information can delay processing.
If a requested drug is non-formulary for the member's plan, submit documentation of medical necessity.
Previous therapies will be verified via pharmacy paid claims or submitted chart notes.

Clinical Definitions

Persistent facial erythema — definition

DefinitionPersistent (non-transient) facial erythema — subtype: erythematotelangiectatic rosacea

Associated diagnostic options on formListed as one of the acceptable diagnoses for brimonidine/oxymetazoline requests

Clinical contextTargeted by topical vasoconstrictors such as brimonidine and oxymetazoline

Papulopustular rosacea — definition

DefinitionPapulopustular rosacea — presence of inflammatory papules and pustules

Required for ivermectin (Soolantra) requestsMember must have papulopustular rosacea with inflammatory lesions

Prior therapy requirementRequires failure of at least 2 listed therapies for >=30 days each within the last 6 months

OpenPayer