CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Tazorac (tazarotene) prior authorization request form

A two-page prior authorization request form used by OptumRx/Blue Cross Blue Shield - South Carolina to collect clinical information for coverage review of tazarotene (Tazorac) topical products for acne vulgaris or plaque psoriasis. The form lists required clinical questions and documentation elements that must be completed for PA processing.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyTazorac (tazarotene) prior authorization request form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must complete and submit the Tazorac prior authorization form with required clinical questions, prescriber's signature, and any supporting information; form may be faxed to 844-403-1029 or initiated via CoverMyMeds/OptumRx.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes noted.

2Primary indications listed (acne vulgaris, plaque psoriasis)

20%Plaque psoriasis BSA threshold

2Topical corticosteroids trial requirement

Policy summary

This is an OptumRx / Blue Cross Blue Shield - South Carolina two-page prior authorization request form for Tazorac (tazarotene) topical products. The form is used to capture necessary clinical information for PA decision-making for the primary indications acne vulgaris and plaque psoriasis, and to collect required documentation elements including indication, prior treatments, contraindications, and pregnancy-risk counseling for females of child-bearing potential.

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The form collects provider and medication details and asks specific clinical questions: diagnosis of acne vulgaris; trial and failure of a generic topical tretinoin or prescriber rationale why tretinoin is inappropriate; diagnosis of plaque psoriasis; affected body surface area (less than 20 percent of total BSA); trial of at least two topical corticosteroids (examples provided) or a documented contraindication; screening for female patients with child-bearing capability and documentation that the prescriber discussed potential fetal harm and need to avoid pregnancy or use birth control; and whether the patient has a diagnosis of cancer. The prescriber's signature and date are required.

Key policy header

PayerBlue Cross Blue Shield - South Carolina

PolicyTazorac (tazarotene) prior authorization request form

Policy CodeN/A

StatusCURRENT

Effective Date

Scope summaryA two-page prior authorization request form used by OptumRx/Blue Cross Blue Shield - South Carolina to collect clinical information for coverage review of tazarotene (Tazorac) topical products for acne vulgaris or plaque psoriasis. The form lists required clinical questions and documentation elements that must be completed for PA processing.

Primary indications (count)2

Plaque psoriasis BSA threshold20%

Topical corticosteroids trial requirement2

Information collected for medical necessity

Acne vulgaris indication criteria (PA information collected)

Form collects responses to determine medical necessity for acne vulgaris:

ALL of the following

Patient has a diagnosis of acne vulgaris
Yes/No checkbox on form
Patient has tried and failed a generic topical tretinoin product
Yes/No checkbox on form
Prescriber deems a generic topical tretinoin product would be inappropriate for the patient
Yes/No checkbox on form
If patient is female with child-bearing capability, prescriber discussed risks of fetal harm and need to avoid pregnancy or use birth control while using tazarotene
Two-part screening: female child-bearing capability (Yes/No) and counseling documented (Yes/No)

Plaque psoriasis indication criteria (PA information collected)

Form collects responses to determine medical necessity for plaque psoriasis:

ALL of the following

Patient has a diagnosis of plaque psoriasis
Yes/No checkbox on form
Affected area(s) is less than 20 percent of total body surface area< 20 percent
Yes/No checkbox on form; threshold explicitly stated as < 20% BSA
Patient has tried at least two topical corticosteroids (examples: triamcinolone, mometasone, fluocinonide, clobetasol)
Yes/No checkbox on form
If corticosteroids not tolerated

Other exclusion/consideration captured on form

Additional clinical information required:

ALL of the following

Does the patient have a diagnosis of cancer?
Yes/No checkbox and free-text field to indicate cancer diagnosis if yes
Prescriber's signature and date confirming information
Signature/date required

What providers must do

Prior Authorization

Submit completed prior authorization form

Provider must complete and submit the Tazorac (tazarotene) prior authorization request form with required clinical questions, prescriber's signature, and any supporting information; form may be faxed to 844-403-1029 or initiated via CoverMyMeds/OptumRx.

Fax: 844-403-1029
Begin online at go.covermymeds.com/OptumRx

Documentation Required

Document prior treatment and counseling

Document trial and failure of generic topical tretinoin for acne or trials of at least two topical corticosteroids (or documented contraindication) for plaque psoriasis; if patient is female with child-bearing potential, document counseling on fetal risk and contraception.

Acne: trial & failure of generic topical tretinoin
Psoriasis: trial of 2 topical corticosteroids OR documented contraindication to topical corticosteroids
Document counseling for females of child-bearing potential on fetal harm and need to avoid pregnancy or use birth control

Denial Risk

Incomplete form may result in denial

Request may be denied unless all required information is received; complete required fields and provide prescriber's signature and date.

Prescriber's signature and date are required

Billing Rule

Contact for PA status/questions

For more information about the prior authorization process, contact 855-811-2218 during posted hours.

Phone: 855-811-2218
Posted hours available on form

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyTazorac (tazarotene) prior authorization request form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

fax	Form may be faxed to 844-403-1029
web	Go to go.covermymeds.com/OptumRx to begin using the service

OpenPayer

Tazorac (tazarotene) prior authorization request form

Policy summary

Information collected for medical necessity

Form / Administrative codes and submission channels

What providers must do

Key definitions

Numeric thresholds and quick facts

Document changes