CurrentAvMedPolicy N/A

Prior authorization and step-edit criteria for Vtama (tapinarof) 1% cream and Zoryve (roflumilast) 0.3% cream

Defines pharmacy prior authorization, step-edit, and clinical criteria for coverage of Vtama (tapinarof) 1% cream and Zoryve (roflumilast) 0.3% cream for plaque psoriasis for AvMed members.

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit criteria for Vtama and Zoryve

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization with prescriber signature, diagnosis, documentation of prior topical therapy trials, and supporting chart notes or pharmacy claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18 / ≥6age requirements

6 moinitial duration

12 more-authorization

60 gquantity limit

Coverage Criteria

Initial Authorization

Covered when ALL of the following are met

Age requirement: Member meets ONE of: age ≥18 for Vtama OR age ≥6 for Zoryveage

checked on form

Diagnosis: Member has a diagnosis of plaque psoriasis

chart notes required

Prior topical corticosteroid trial: History of failure, contraindication, or intolerance to 30 days (14 days for very high potency) of one topical corticosteroid within past 180 days30 days (14 if very high potency)

Policy Summary

PayerAvMed

PolicyPrior authorization and step-edit criteria for Vtama and Zoryve

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization with prescriber signature, diagnosis, documentation of prior topical therapy trials, and supporting chart notes or pharmacy claims.

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.

pharmacy claims or chart notes will be used to verify

Prior other topical agent trial: History of failure, contraindication, or intolerance to 30 days of one other topical agent used for psoriasis (e.g., calcipotriene, tacrolimus, tazarotene) within past 180 days30 days

tazarotene requires prior authorization; trials verified by pharmacy claims or chart notes

Reauthorization / Continued Therapy

Reauthorization requires:

Clinical response: Member has experienced disease improvement and/or stabilization of plaque psoriasis

chart notes documenting improvement/stabilization must be submitted

Not all drugs may be covered under every Plan. If the requested agent is non-formulary for the member's Plan, the prescriber must provide documentation of medical necessity to support coverage. This documentation should be included with the prior authorization request and may be used in the coverage determination.

The use of free or sample product to start therapy does not meet the policy's step-edit or prior authorization trial requirements and will not satisfy the required prior therapy trials. Providers must document completed trials via pharmacy paid claims or chart notes showing the required durations and outcomes; samples alone are insufficient.

Coding and Diagnostic Codes

ICD-10 / diagnosisICD-10

ICD code if applicable

Member's diagnosis ICD code to be provided when applicable

Topical corticosteroid trial duration

Topical corticosteroid trial duration30 days (14 days for very high potency)

Verification windowTrials must be within the past 180 days and will be verified via pharmacy claims or chart notes

Acceptable evidenceChart notes documenting failure, contraindication, or intolerance must be attached

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Vtama (tapinarof) 1% cream and Zoryve (roflumilast) 0.3% cream. Initial approvals are for up to 6 months; reauthorization is 12 months. Quantity limit: 60 grams (1 tube) per 30 days. Not all drugs may be covered under every plan; if non‑formulary, medical necessity documentation is required.

Drugs requiring PA: Vtama (tapinarof) 1% cream; Zoryve (roflumilast) 0.3% cream
Initial Authorization: up to 6 months; Reauthorization: 12 months
Quantity limit: 60 grams (1 tube) per 30 days
Age requirements: Vtama ≥ 18 years; Zoryve ≥ 6 years

Step Therapy

Step Therapy / Prior Topical Trials

Members must have a documented history of failure, contraindication, or intolerance to required topical therapies before approval. Use of samples to initiate therapy does not satisfy step-edit/prior authorization requirements. Previous therapies will be verified via pharmacy paid claims or submitted chart notes.

Member must have plaque psoriasis diagnosis
Step requirements (both must be met unless contraindicated/intolerant): 1) 30 days (14 days if very high potency) of one topical corticosteroid within past 180 days; 2) 30 days of one other topical psoriasis agent (e.g., calcipotriene 0.05% ointment/solution, tacrolimus 0.01% or 0.03% ointment, or tazarotene 0.1% cream) within past 180 days
Chart notes must document contraindication(s) or intolerance if relying on those reasons

Documentation Required

Form Completeness and Signature Required

Complete the pharmacy prior authorization form in full. The prescribing physician must sign and clearly print their name (preprinted stamps are not valid). Incomplete, incorrect, or illegible forms, or missing provider signature, may delay processing or result in denial.

Required on PA form: prescriber signature and printed name (no stamps), patient identifiers, drug name/formulation/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, date, and phone/fax contact information
If information is incomplete, incorrect, or illegible, authorization may be delayed or denied

Denial Risk

Clinical Documentation Must Be Submitted

All clinical documentation that supports criteria checked on the PA form must be provided. Authorization may be denied if chart notes, lab results, diagnostics, or evidence of prior therapy trials are not submitted.

Attach chart notes documenting diagnosis, prior topical therapy trials, contraindications, or intolerances
Provide relevant labs or diagnostics when applicable
Previous therapy verification may be performed via pharmacy claims and/or submitted chart notes

Background

This prior authorization applies to topical prescription therapies for plaque psoriasis, specifically Vtama (tapinarof) 1% cream and Zoryve (roflumilast) 0.3% cream. Initial approvals are granted for 6 months with reauthorization available for 12 months. Age requirements vary by product: Vtama — age ≥18; Zoryve — age ≥6. Prior to approval, the member must have documented a diagnosis of plaque psoriasis and evidence of failure, contraindication, or intolerance to BOTH of the following within the past 180 days: (1) a trial of one topical corticosteroid for 30 days (14 days if very high potency), and (2) a trial of one other topical psoriasis agent for 30 days (examples: calcipotriene, tacrolimus, tazarotene). Trials will be verified via pharmacy claims or submitted chart notes.

Definitions

Plaque psoriasis (definition / note)

DefinitionPlaque psoriasis

Documentation requiredChart notes confirming diagnosis must be provided to support approval

Relationship to coverageDiagnosis of plaque psoriasis is required for approval of Vtama or Zoryve

Initial Therapy Criteria

Initial Therapy

Initial authorization parameters

Duration: Initial authorization duration is 6 months6 months

Age requirement: ≥18 years for Vtama; ≥6 years for Zoryveage

checked on form

Quantity limit: 60 grams (1 tube) per 30 days60 grams per 30 days

Continuation / Reauthorization Criteria

Continuation Therapy

Reauthorization requirements

Reauthorization clinical requirement: Member has experienced disease improvement and/or stabilization of plaque psoriasis; chart notes must be submitted

12 month reauthorization period

Step Therapy Requirements

Required prior trials	Duration / timing	Notes
Topical corticosteroid (one agent)	30 days (14 days if very high potency) within the past 180 days	History of failure, contraindication, or intolerance required; trials verified via pharmacy claims or chart notes
Other topical psoriasis agent (one agent) e.g., calcipotriene, tacrolimus, tazarotene	30 days within the past 180 days	Tazarotene requires prior authorization; chart notes documenting contraindication(s) or intolerance must be attached; trials verified via pharmacy claims or chart notes

Quantity Limits

Vtama or Zoryve — quantity limit

Quantity limit60 grams (1 tube) per 30 days

Form fieldQuantity limits are specified on the prior authorization drug information section

VerificationAuthorization may be delayed if the PA form is incomplete; provide dosing schedule and length of therapy