CurrentCentenePolicy CP.PMN.208

Halobetasol Propionate/Tazarotene (Duobrii) topical lotion

Medical necessity and prior authorization criteria for Duobrii lotion for treatment of plaque psoriasis in adults under Centene-affiliated health plans (Commercial, HIM, Medicaid).

Policy Summary

PayerCentene

PolicyHalobetasol Propionate/Tazarotene (Duobrii) topical lotion

Policy CodePolicy CP.PMN.208

Change TypeAdded step therapy bypass for Illinois HIM

Effective DateSep 1, 2019

Next Review Date

Key ActionSubmit prior authorization with documentation showing criteria are met, including prior failures of specified generics unless contraindicated.

SourceLink

POLICY UPDATE CHANGES

Added step therapy bypass for Illinois HIM per IL HB 5395.

≤ 20%Maximum BSA for initial approval

≥ 18Minimum age for approval

100 g/moMaximum dose allowed

12 moApproval duration

pregnancyContraindication

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Coverage Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial Approval - Plaque Psoriasis: 1) Diagnosis of plaque psoriasis (PsO) with body surface area involvement ≤ 20%; 2) Age ≥ 18 years; 3) Prescribed by or in consultation with a dermatologist or rheumatologist; 4) Failure of generic halobetasol propionate and generic clobetasol propionate unless both are contraindicated or cause clinically significant adverse effects (step therapy requirements do not apply for Illinois HIM requests per IL HB 5395 effective 1/1/2026); 5) Failure of generic tazarotene unless contraindicated or causes clinically significant adverse effects (step therapy requirement does not apply for Illinois HIM requests per IL HB 5395 effective 1/1/2026); 6) Dose does not exceed 100 g per month (one tube per month).see node text

Approval duration: 12 months

Continuation Therapy

Covered when ALL of the following are met:

Continued Therapy - Plaque Psoriasis: 1) Member is currently receiving medication via Centene benefit or has previously met initial approval criteria, or continuity of care provisions apply; 2) Member is responding positively to therapy; 3) If request is for a dose increase, the new dose does not exceed 100 g per month (one tube per month).see node text

Approval duration: 12 months

Non‑FDA approved indications that are not specifically addressed in this policy are not authorized for coverage unless the provider submits sufficient documentation of efficacy and safety in accordance with applicable off‑label use policies (see CP.CPA.09 for Commercial, HIM.PA.154 for Health Insurance Marketplace, and CP.PMN.53 for Medicaid).

Use of Duobrii for non‑FDA approved indications that lack adequate supporting evidence or are not permitted under the referenced off‑label policies is considered not authorized and may be denied without adequate clinical justification.

Provider Actions / Requirements

Prior Authorization

Prior authorization required

Prior authorization is required. Approval is contingent on documentation that all coverage criteria are met, including meeting the Initial Approval Criteria for plaque psoriasis and documented prior failures of specified generics when applicable; dose must not exceed 100 g per month.

Step Therapy

Step therapy requirements and IL HIM bypass

Step therapy must be documented: member must have failed generic halobetasol propionate and generic clobetasol propionate, and failed generic tazarotene, unless these agents are contraindicated or cause clinically significant adverse effects. For Illinois HIM requests, the step therapy requirements do not apply effective 1/1/2026 per IL HB 5395.

Failure of generic halobetasol propionate and generic clobetasol propionate required unless contraindicated or significant adverse effects.
Failure of generic tazarotene required unless contraindicated or significant adverse effects.
IL HIM requests are exempt from step therapy starting 1/1/2026 per IL HB 5395.

Documentation Required

Required documentation

Submit supporting clinical documentation with the prior authorization request (for example, office chart notes, laboratory results, or other clinical information) demonstrating the member meets all approval criteria.

Include documentation of diagnosis, BSA, prior therapy trials, contraindications or adverse effects if claiming exemptions, and current dosing.
Ensure documentation supports any continuity or response claims for continuation requests.

Denial Risk

Insufficient documentation or non‑covered indication

Requests lacking documentation that the member meets all approval criteria may be denied; requests for non‑FDA approved indications that do not include sufficient evidence of efficacy and safety per off‑label use policies will not be authorized.

Non‑FDA indications require sufficient documentation per CP.CPA.09 (Commercial), HIM.PA.154 (HIM), or CP.PMN.53 (Medicaid).
Insufficient clinical information to demonstrate criteria are met can lead to denial.

OpenPayer

Halobetasol Propionate/Tazarotene (Duobrii) topical lotion

Coverage Criteria

Coding

Provider Actions / Requirements

Definitions

Background