ModifiedBlue Cross Blue Shield - MassachusettsPolicy 010

Medications for skin conditions (step therapy, prior authorization, quantity limits)

Rules for step therapy, prior authorization, and quantity-limit requirements for medications used to treat skin conditions (e.g., atopic dermatitis) for BCBSMA commercial members and certain Medicare Advantage plans.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedications for skin conditions (step therapy, prior authorization, quantity limits)

Policy CodePolicy 010

Change TypeMultiple material and non-material updates (drug additions, step changes, criteria clarifications)

Effective Date

Next Review Date

Key ActionSubmit prior authorization using the Massachusetts Standard Form and include documentation of formulary alternatives tried and failed with dates when available.

SourceLink

POLICY UPDATE CHANGES

Removed oral systemic DMARD requirement for Rinvoq's atopic dermatitis indication.

Added Leqselvi to the policy.

Clarified step table for Adbry and Cibinqo and added separate pre-requisites for Zoryve Foam due to different indication.

Added Prescriber requirement to Rinvoq for Atopic Dermatitis.

Added Zoryve foam & Cream as Step 3 in the policy and moved Eucrisa to Step 2 in the respective table.

Removed corticosteroid trial for Rinvoq (prior version had corticosteroid trial requirement).

Updated Rinvoq criteria to add trial of topical corticosteroid and topical calcineurin inhibitor (prior to removal in later update).

Reformatted policy on multiple occasions (2023 entries).

130look-back days

2formulary trials required

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Coverage Criteria for Dermatology Medications

Leqselvi (deurxolitinib) coverage criteria

Leqselvi may be covered when ALL of the following are met

Leqselvi coverage: Age is equal to or greater than 18 years of age

Leqselvi coverage: Confirmed diagnosis of alopecia areata

Litfulo (ritlecitinib) coverage criteria

Litfulo may be covered when ALL of the following are met

Litfulo coverage: Age is equal to or greater than 12 years of age

Litfulo coverage: Confirmed diagnosis of alopecia areata

Rinvoq (upadacitinib) coverage criteria for atopic dermatitis

Rinvoq may be covered when ALL of the following are met

Rinvoq - moderate to severe AD: The patient has moderate-to-severe atopic dermatitis (eczema)

Rinvoq - moderate to severe AD: The patient is 12 years of age or older

Rinvoq - moderate to severe AD: Demonstrated treatment failure with a 14-day trial of a prescription topical corticosteroid OR topical calcineurin inhibitor (documented in claims history or prior treatment)

Rinvoq - moderate to severe AD: Prescribed by a board-certified or board-eligible Allergist or Dermatologist

Requests for non-formulary or non-covered biologic agents require documented evidence that the member has had treatment failure with, or a contraindication to, at least two covered formulary alternatives when available, and the diagnosis must be confirmed to be within the FDA-labeled indication. This requirement aligns with the biologic agents table which specifies that NFNC agents (for example, Adbry and Cibinqo) require a trial of two (2) of the formulary medications above prior to use and confirmation of an FDA-labeled diagnosis.

All medications listed in the policy that are subject to non-formulary/non-covered status remain subject to the prior authorization process. For non-covered medications, approval of an exception may be granted only after the required trials of formulary alternatives and confirmation of diagnosis are documented in the prior authorization submission.

Requests based solely on the use of free samples will not satisfy the requirements for an exception to coverage. When a prescriber submits an exception request that relies on samples, the request must include additional clinical information demonstrating medical necessity for the requested medication before it can be considered.

Acceptable supporting information includes clinical notes and documentation that clearly explain why formulary alternatives are not appropriate (for example, treatment failure or contraindication). Providers should include this material with the prior authorization or exception submission to avoid delays or denials.

Coding and Clinical Thresholds

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Many medications listed in this policy require prior authorization (PA) before BCBSMA will approve coverage. For non‑covered (non‑formulary) drugs, the member must generally have had prior treatment failures with, or contraindications to, at least two covered formulary alternatives when available. A higher non‑preferred cost share may apply if an exception request is approved for a non‑preferred or non‑formulary/non‑covered drug.

All PA rules in this policy apply to BCBSMA commercial formularies (HMO/POS, PPO/EPO, Indemnity, MEDEX with Rx, Managed Blue for Seniors)

Note

How to Submit a Prior Authorization Request

Submit prior authorization requests using the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or the printable Formulary Exception/Prior Authorization form. Providers may call, fax, or mail the completed form. See the BCBSMA eForm instructions link for details and acceptable submission methods.

eForm link: https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/023%20E%20Form%20medication%20prior%20auth%20instruction%20prn.pdf

Definitions and Key Terms

Abbreviations used in this policy

QCDQuality Care Dosing (quantity limits policy #621B)

STStep Therapy

PAPrior Authorization

NFNCNonformulary / Non-covered

Individual Consideration (Exception Request) definition

Supporting documentation recommendedInclude clinical notes or statements; name and strength of formulary alternatives tried and failed with specifics of treatment failure; clinical literature and compendia references; consensus or guideline documents.

Submission methods

Background and Scope

This policy governs the use of topical and systemic therapies for dermatologic conditions such as atopic dermatitis and alopecia areata, and aligns formulary placement with step therapy (ST), prior authorization (PA), and Quality Care Dosing (QCD) quantity limits. It references related policies for certain biologics and immune-modulating drugs to ensure consistent application of coverage rules across specialized products.

Providers seeking prior authorization or exception consideration should follow the submission instructions in the Appendix and include the required supporting documentation; Pharmacy Operations contact information and specialty fill requirements are provided for operational coordination.

Policy Revision History

2026-01policy_updateLatest

Removed oral systemic DMARD requirement for Rinvoq's atopic dermatitis indication; updated formatting.

2025-11addition_and_relocation

Added Leqselvi to the policy and moved Litfulo from Medical Policy #049 to Policy #010 for consistency.

2025-06clarification

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMedications for skin conditions (step therapy, prior authorization, quantity limits)

Policy CodePolicy 010

Change TypeMultiple material and non-material updates (drug additions, step changes, criteria clarifications)

Effective Date

Next Review Date

Key ActionSubmit prior authorization using the Massachusetts Standard Form and include documentation of formulary alternatives tried and failed with dates when available.

SourceLink

On This Page

Billing Rule

Specialty Pharmacy Fill Requirement

Specialty‑designated medications billed under the pharmacy benefit must be dispensed through a BCBSMA retail specialty pharmacy network provider (except for Medex/Medicare plans where noted).

Members (other than Medex®; Blue MedicareRx, Medicare Advantage plans that include prescription drug coverage) must fill specialty meds at a BCBSMA specialty network pharmacy
See BCBSMA Specialty Pharmacy List for participating providers

Documentation Required

Required Supporting Documentation

Providers must include supporting documentation that demonstrates prior trials of formulary alternatives or clinical reasons preventing use of formulary alternatives. At minimum, documentation should list the name and strength of alternatives tried and failed (including dates if available) and specifics regarding the treatment failure or contraindication.

Prescription claims may be used by BCBSMA to establish prior use of formulary alternatives — if claims data is incomplete, the provider must supply additional evidence
Failure to provide documentation of prior trials may result in denial or the need for additional review

Documentation Required

Supporting Clinical Documentation for Exception Requests

For exception (individual consideration) requests, include clinical notes or supporting statements that explain the member’s unique circumstances. Useful materials include names/strengths and dates of failed therapies, clinical rationale why switching to a formulary alternative is not appropriate, relevant peer‑reviewed literature or compendia references, and consensus guideline citations.

Clinical notes or provider statements describing contraindications, adverse effects, or expected ineffectiveness
Names, strengths, and dates of formulary alternatives tried and reason for failure
Copies of pertinent clinical literature or references from AHFS‑DI, Lexi‑Drug, Clinical Pharmacology, Micromedex, Drugdex, or national guidelines

Step Therapy

Step Therapy Summary (Topical & Systemic Agents)

Step therapy applies across topical and systemic agent groups in this policy. Topical and systemic medications are organized into step tables (e.g., Step 1 = topical corticosteroids and other first‑line agents; Step 2 = select nonsteroidal/topical prescription agents such as Eucrisa, Opzelura; Step 3 = advanced topicals or non‑formulary agents; systemic tables include biologics and oral JAK/PD4 agents). Many agents require prior use of one or more medications from prior steps within a specified look‑back period (commonly 130 days) before coverage of a higher‑step agent is considered.

Topical step table: topical corticosteroids and other Step 1 agents are generally covered with no requirements; Step 2 and Step 3 topical agents require prior trials as specified in the topical tables
Systemic/biologic step table: biologic and systemic agents have PA and step requirements; some systemic agents are subject to Quality Care Dosing (QCD) quantity limits

Step Therapy

Step Therapy Tables Exist for Topical and Systemic Agents

Detailed step therapy placement tables for topical and systemic agents are included in this policy (see sections titled 'Step Therapy for Calcineurin Inhibitors, PD4 inhibitors, and JAK inhibitors', 'Step Therapy for Aryl Hydrocarbon Receptor Agonists', and 'Biologic Agents for Skin Conditions Table'). These tables specify the step number, formulary status (e.g., Covered, ST, PA, NF, NFNC), required prior trials (number and class of agents), and any applicable look‑back period (commonly 130 days).

Topical tables define Step 1 (topical corticosteroids and similar first‑line agents), Step 2 (e.g., Eucrisa, Opzelura, topical calcineurin inhibitors) and Step 3 (e.g., Elidel, Protopic, Zoryve) with explicit prior trial requirements
Systemic/biologic tables identify which agents require PA, QCD, or are non‑formulary/non‑covered and outline trials of formulary agents required before NF/NFNC agents may be considered