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Dermatology - Vtama Drug Quantity Management Policy - Per Days
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Defines quantity limits and exception criteria for coverage of Vtama topical cream for Cigna-administered health benefit plans, affecting prescribers and pharmacy prior authorization processes.
No material clinical or coverage changes in this revision.
Coverage Criteria and Exceptions
Quantity Limit Exception
Exceptions to the standard quantity limits are covered as medically necessary when the following is met:
Any other exception is considered not medically necessary.
Any exception to the listed quantity limits that does not meet the stated criteria is considered not medically necessary. Specifically, exceptions are only covered when the documented clinical situation meets the criteria described for increased quantity (see criteria below).
Requests for quantities exceeding the stated maxima are considered not medically necessary unless they meet the exception criteria. The standard maximums are 60 g per 30 days (retail) and 180 g per 90 days (home delivery); the allowable exception limits are 360 g per 30 days (retail) and 1080 g per 90 days (home delivery) when the criteria are met. Any request that exceeds these exception maxima or is not justified by treatment of >8% BSA should be denied as not medically necessary.
Product Coding and Quantity Assumptions
| tapinarof 1% cream | Vtama topical cream, 60 g tube |
Provider Actions, Prior Authorization, and Documentation
Quantity management / prior authorization overview
Quantity management is enforced at the point of service; exceptions to standard quantity limits require meeting the clinical criteria described in the policy and approvals are valid for 1 year.
- Standard retail maximum: 60 g per 30 days (one 60 g tube).
- Standard home delivery maximum: 180 g per 90 days (three 60 g tubes).
- Exceptions covered only when criteria for treating >8% BSA are met (see criteria).
- Meeting quantity management criteria does not satisfy other prior authorization or medical necessity requirements.
No step therapy specified
This policy does not specify any step therapy requirements for Vtama.
Documentation required for quantity exceptions
Provide documentation demonstrating medical necessity to justify quantities above the standard limits; all approvals are issued for 1 year and meeting quantity criteria does not remove other prior authorization or medical necessity obligations.
- Documentation should support treatment of >8% body surface area when requesting quantities above standard maxima.
- Approvals granted under this Drug Quantity Management program are valid for one year.
Point-of-service adjudication and denial risk
If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the policy Criteria below; failure to meet those criteria may result in denial.
- Criteria allow exceptions only when treating >8% BSA and within maximums of 360 g/30 days retail or 1080 g/90 days home delivery.
- Requests exceeding those maxima or not justified by >8% BSA are considered not medically necessary.
Background
Vtama (tapinarof 1% cream) is supplied as a 60 gram tube. Quantity limits are based on this tube size with a standard dispensing allowance of 60 g per 30 days (one tube) and a home delivery allowance of 180 g per 90 days (three tubes). Clinical trials enrolled patients with mean body surface area involvement consistent with these assumptions; when a patient requires treatment of greater than 8% BSA, an exception may be approved up to 360 g per 30 days (6 tubes retail) or 1080 g per 90 days (18 tubes home delivery) as described in the criteria.
Definitions
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