CurrentBlue Cross Blue Shield - MassachusettsPolicy 010

Prior Authorization and Step Therapy for Dermatologic Medications

Governs prior authorization, step therapy, and quantity limit requirements for medications used to treat skin conditions (e.g., atopic dermatitis) for BCBSMA commercial members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyPrior Authorization and Step Therapy for Dermatologic Medications

Policy CodePolicy 010

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests using the Massachusetts Standard Form #434 (eForm or print-and-fax) with documentation of prior trials and supporting clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical length of approval

130 dayslook-back period

90 daystopical prior use window

Form #434PA form referenced

Coverage Criteria

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Rinvoq coverage: 1) Patient has moderate-to-severe atopic dermatitis (eczema); AND 2) Inadequate response to at least ONE other systemic immunosuppressant (e.g., methotrexate, cyclosporine, mycophenolate, azathioprine) OR when other systemic drugs are contraindicated OR the patient has claim history of ONE of pimecrolimus or tacrolimus topical within the previous 90 days; AND 3) Patient is 12 years of age or older; AND 4) Demonstrated treatment failure with a 14-day trial of a prescription topical corticosteroid in claims history or previous treatment; AND 5) Drug is prescribed by a board-certified or board-eligible Allergist or Dermatologist; AND 6) Documented dose and frequency submitted are within FDA-approved dosing and frequency.

From policy text

Biologics prerequisites

Biologic agents for skin conditions require:

Biologics prerequisites: 1) Documented FDA-labeled diagnosis; AND 2) Meet the step therapy requirements described in the policy (see biologics table).

Applies to biologic agents listed

Coding and Forms

Prior authorization forms referencedmixed

434	Massachusetts Standard Form for Medication Prior Authorization Requests #434

inv-07: Minimum age for Rinvoq

Minimum age>= 12 years

IndicationModerate-to-severe atopic dermatitis

Supporting criterionInadequate response to at least one other systemic immunosuppressant or prior topical pimecrolimus/tacrolimus within previous 90 days

Provider Actions and Requirements

Prior Authorization

Prior Authorization Requirements

Prior Authorization Required: Certain agents require prior authorization (PA) before coverage. Length of approval for approved PAs is 12 months. For non‑covered (non‑formulary) medications, the member must have documentation of treatment failure with, or contraindication to, at least two covered formulary alternatives when available. If an exception is approved for a non‑preferred or non‑formulary drug, a higher non‑preferred member cost share may apply.

Length of approval: 12 months.
Non‑formulary/non‑covered drugs: documented failure or contraindication to ≥2 covered formulary alternatives required prior to coverage.
Examples of PA drugs: Dupixent (dupilumab) and Rinvoq (upadacitinib) require PA; see related coverage criteria or policy #033 where noted.

Note

Prior Authorization Form and Submission

All PA requests must be submitted using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm). You may submit electronically via the eForm link or print and fax the Standard Form #434.

Use the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm).
If not submitted electronically, print and fax Massachusetts Standard Form #434.

Step Therapy

Step Therapy General Rules

Step therapy is required for many topical and systemic dermatologic agents. Topical corticosteroids are the first‑line (Step 1) therapy and are covered with no step requirements. Subsequent steps require documented prior use of specified lower‑step agents within the prior 130 days, with numeric step progression required for many products.

Step 1 (first‑line): Topical corticosteroids — covered with no requirements.
Step 2: Many topical calcineurin inhibitors, PD4 inhibitors, and some JAK inhibitors (e.g., Eucrisa, Opzelura, topical pimecrolimus/tacrolimus) require prior use of ONE Step 1 medication or history of prior use of any Step 2 medication in the table within the previous 130 days.
Step 3: Certain agents (e.g., Protopic/tacrolimus, Elidel/pimecrolimus, and roflumilast products) require prior use of TWO Step 2 medications or history of prior use of a Step 3 medication in the table within the previous 130 days.
Non‑formulary topical products (NF) may require demonstration of trials of specific formulary alternatives (e.g., topical corticosteroids, topical calcineurin inhibitors, topical antifungals) prior to approval.

Documentation Required

Required Supporting Documentation

Documentation that supports prior use or clinical reasons preventing trial of formulary alternatives is required. The plan will use prescription claims to verify prior use within the previous 130 days when available; when claims data are not available or insufficient, the provider must supply documentation.

Required supporting documentation must include drug name and strength for alternatives tried, dates of use if available, and specifics regarding the reason for treatment failure.
If clinical reasons prevent trial of formulary alternatives, provide a detailed clinical rationale explaining why alternatives were contraindicated or inappropriate.
Historic prescription claim records may be used; if they do not establish prior use, submit additional provider documentation to confirm prior trials or contraindications.

Background

This policy covers medications used to treat skin conditions such as atopic dermatitis and consolidates step therapy, prior authorization, and quantity‑limit rules for topical agents, calcineurin inhibitors, PDE4 inhibitors, JAK inhibitors, aryl hydrocarbon receptor agonists, and biologics. It centralizes prior authorization and step‑therapy pathways (for example, requirements for biologic agents and the Rinvoq pathway) so that prescribing clinicians and operational staff follow a single, consolidated set of requirements for dermatologic therapies.

Definitions

inv-17: QCD — Quality Care Dosing (quantity limits policy #621B)

DefinitionQuality Care Dosing (QCD) refers to quantity limits policy #621B

Associated agentsEbglyss (lebrikizumab) and Rinvoq (upadacitinib) listed with QCD in biologics table

Policy relationSee related policy #621B for specific quantity limit rules

inv-18: NFNC — Nonformulary, Non-covered

DefinitionNFNC = Nonformulary, Non-covered

Example agentsAdbry (tralokinumab) and Cibinqo (abrocitinib) listed as NFNC in biologics table

Requirement before NFNC useTrial of two formulary medications above and confirm diagnosis is within FDA label prior to NFNC use

inv-19: PA — Prior Authorization required

RequirementPA = Prior Authorization required

Applies toSelected biologics and systemic agents (e.g., Dupixent, Rinvoq, lebrikizumab) listed as PA in biologics table

SubmissionPrior authorization requests must be submitted using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or form #434