Topical Alpha-Adrenergic Agonists for Rosacea - Brimonidine Prior Authorization Policy
Defines prior authorization requirements and coverage criteria for topical brimonidine 0.33% gel (Mirvaso and generic) for treatment of persistent facial erythema of rosacea for Cigna-administered health benefit plans.
Annual Revision with summary: No criteria changes.
Coverage Summary
Brimonidine 0.33% gel (Mirvaso and generic) is covered with criteria for the FDA‑approved indication of topical treatment of persistent facial erythema of rosacea in adults. Prior authorization is required for coverage. Approvals are provided for 1 year when the coverage criteria are met, and the policy applies to Cigna‑administered health benefit plans. Age requirement: ≥ 18 years.
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