CurrentCignaPolicy N/A

PRIOR AUTHORIZATION POLICY

Defines prior authorization recommendation and coverage criteria for prescription topical tazarotene products (Arazlo, Fabior, Tazorac) for FDA‑approved indications and other non‑cosmetic medical uses; excludes cosmetic use. Applies to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyPRIOR AUTHORIZATION POLICY

Policy CodePolicy N/A

Change TypeAnnual revision — no criteria changes

Effective Date

Next Review Date

Key ActionPrior authorization is recommended; document the FDA‑approved indication or specific non‑cosmetic condition to support authorization and reimbursement.

SourceLink

POLICY UPDATE CHANGES

Annual Revision notes indicate 'No criteria changes' with last review date 08/13/2025.

3Products Addressed

2FDA‑Approved Indications

1 yearApproval Duration (per indication)

NoPolicy Change Flag

Coverage Summary

This policy defines prior authorization requirements for prescription topical tazarotene products — Arazlo (tazarotene 0.045% lotion), Fabior (tazarotene 0.1% foam), and Tazorac (tazarotene 0.05% cream/gel and 0.1% cream/gel; generics limited to 0.1% cream, 0.05% gel, and 0.1% gel) and states that these products are covered with criteria when used for FDA‑approved indications or selected non‑cosmetic medical uses.

Coverage is provided for the specified FDA‑approved indications — 2 approved indications (acne vulgaris and plaque psoriasis) — with approvals generally authorized for 1 year. Cosmetic uses are excluded from prescription benefit coverage.

Medical Necessity Criteria

Topical tazarotene products are covered as medically necessary when ALL of the following are met for FDA‑approved indications or other uses with supportive evidence:

ALL of the following

Products Covered When Criteria Met: Medication is one of the following products: Arazlo (tazarotene 0.045% lotion), Fabior (tazarotene 0.1% foam), or Tazorac (tazarotene 0.05% cream, 0.05% gel, 0.1% cream, 0.1% gel [generics coverage limited to 0.1% cream, 0.05% gel, and 0.1% gel])
Indication
- Acne vulgaris — FDA‑approved indication
  Approval duration: 1 year
- Plaque psoriasis — FDA‑approved indication
  Approval duration: 1 year
- Other non-cosmetic dermatologic conditions: Other non‑cosmetic dermatologic conditions with supportive evidence
  Approval duration: 1 year

Examples of Other Non‑Cosmetic Conditions (supportive evidence)

Examples include but are not limited to:

Examples of Other Non-Cosmetic Conditions (supportive evidence)

Acne keloidalis nuchae
Basal cell carcinoma
Comedonal acne
Cystic acne
Cutaneous T‑cell lymphoma
Ichthyosis (congenital, lamellar, vulgaris, X‑linked)
Keratoderma blennorrhagicum
Keratosis (e.g., Darier's disease, keratosis pilaris)
Mycosis fungoides
Nail psoriasis
Oral lichen planus
Warts

Not Medically Necessary (Exclusions)

Topical tazarotene products are considered not medically necessary for ANY other uses including, but not limited to, the following cosmetic indications:

Excluded/Cosmetic Indications

Cosmetic use (excluded from coverage under typical pharmacy benefit)
Actinic purpura
Age spots / solar lentigines / sun spots
Melasma / chloasma
Milia
Mottled hyperpigmentation
Mottled hypopigmentation
Photo‑aged or photo‑damaged skin
Poikiloderma (of Civatte)
Premature aging
Scarring
Sebaceous hyperplasia
Seborrheic keratosis
Skin laxity
Skin roughness
Solar elastosis
Solar purpura
Stretch marks
Wrinkles

Cosmetic use refers to use intended for aesthetic improvement (for example, wrinkles, photoaging, age spots) and is excluded from typical pharmacy benefit coverage; requests billed for cosmetic indications will be denied as not covered.

Coding

Products Covered When Criteria MetmixedCovered

Arazlo	tazarotene 0.045% lotion (Bausch Health)
Fabior	tazarotene 0.1% foam (Mayne Pharma, generic)
Tazorac	tazarotene 0.05% cream, 0.05% gel, 0.1% cream, 0.1% gel (Allergan; generics to 0.1% cream, 0.05% gel, and 0.1% gel only)

Cosmetic/Not Covered UsesmixedNot Covered

Cosmetic use

Any cosmetic indication such as wrinkles, photoaging, age spots, etc.

Provider Actions / Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is recommended for prescription benefit coverage of topical tazarotene products. All approvals are provided for the duration noted for approved indications.

Approval duration typically 1 year for approved indications

Documentation Required

Indication Documentation

Provider must document the FDA‑approved indication or the specific non‑cosmetic medical condition being treated to support authorization and reimbursement. Examples of other non‑cosmetic conditions are provided in the policy and should be included in documentation when applicable.

Document the FDA‑approved indication (acne vulgaris or plaque psoriasis) or the specific non‑cosmetic condition (see examples in policy)

Denial Risk

Claims Denial for Noncovered Uses

Claims submitted for cosmetic indications or for services not accompanied by covered diagnosis codes under this policy will be denied as not covered.

Background

Topical tazarotene products are indicated primarily for acne vulgaris and plaque psoriasis, and have also been used off‑label for various other non‑cosmetic dermatologic conditions (examples include basal cell carcinoma, congenital ichthyoses, keratoses, nail psoriasis, cutaneous T‑cell lymphoma, and others).

Coverage policies provide the framework to interpret typical pharmacy benefit exclusions for cosmetic uses and to guide prior authorization decisions for FDA‑approved and other medically necessary non‑cosmetic indications. Prescribing information and published literature are referenced to support these determinations.

Evidence / References

Prescribing information and literature cited: multiple manufacturer prescribing information documents (2018–2024) and supportive publications/reviews are referenced to support indications and other non‑cosmetic uses (see manufacturer PI and cited clinical literature).

Term	Definition
Cosmetic use	Use intended for aesthetic improvement (e.g., wrinkles, photoaging, age spots) which is excluded from typical pharmacy benefit coverage.

Revision History

2023-08-02annual_review

Annual Revision notes indicate No criteria changes

2025-08-13annual_reviewLatest