ModifiedCignaPolicy IP0174

Topical Retinoids - Tazarotene Products

Cigna drug coverage policy defining prior authorization requirements, approved indications (acne vulgaris, plaque psoriasis, other non-cosmetic conditions), product-specific criteria, and exclusions for topical tazarotene products for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyTopical Retinoids - Tazarotene Products

Policy CodePolicy IP0174

Change TypeTitle updatePreferred table language added

Effective DateDec 15, 2025

Next Review Date

Key ActionPrior Authorization is required; approvals are provided for 1 year when criteria are met and providers must document prior trials or intolerance to required comparator products.

SourceLink

POLICY UPDATE CHANGES

Policy title updated from 'Topical Tazarotene Products' to 'Topical Retinoids - Tazarotene Products'.

Added standardized approval language: 'Approve for 1 year when Preferred product criteria are met for the products listed in the below table(s)' for Acne Vulgaris, Plaque Psoriasis, and Other Non-Cosmetic Conditions.

Removed Tazorac 0.05% cream and 0.1% cream from unspecified location(s) in prior formatting.

3Main Indications Covered

1 yrApproval Duration

CosmeticNot Covered

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Coverage Summary

Coverage stance: covered with criteria for topical tazarotene products (Arazlo, Fabior, Tazorac) for their primary approved indications: acne vulgaris and plaque psoriasis, and for certain other non-cosmetic dermatologic conditions. Prior Authorization is required. Approvals are provided for 1 year when criteria are met. Policy effective date: 12/15/2025.

Key Facts

Main Indications Covered3 (Acne vulgaris; Plaque psoriasis; Other non-cosmetic conditions)

Approval DurationApprove for 1 year when Preferred product criteria are met

Not CoveredCosmetic uses are excluded from coverage (not medically necessary)

Policy Effective Date / RevisionAnnual revision dated 12/15/2025 (title updated to 'Topical Retinoids - Tazarotene Products')

Prior AuthorizationPrior Authorization required; approvals provided for 1 year when criteria are met

Initial Therapy Criteria

Prior Authorization / FDA-Approved Indications

Prior Authorization is required. Approvals provided for 1 year when criteria are met.

ANY of the following

Acne Vulgaris (FDA-approved)
- Approve for 1 year when Preferred product criteria are met for the products listed in the below table(s)
Plaque Psoriasis (FDA-approved)
- Approve for 1 year when Preferred product criteria are met for the products listed in the below table(s)
Other Non-Cosmetic Conditions (supportive evidence)
- Approve for 1 year when Preferred product criteria are met for the products listed in the below table(s)
- Examples include acne keloidalis nuchae, basal cell carcinoma, comedonal acne, cystic acne, cutaneous T-cell lymphoma, ichthyosis (congenital, lamellar, vulgaris, X-linked), keratoderma blennorrhagicum, keratosis (Darier's disease, keratosis pilaris), mycosis fungoides, nail psoriasis, oral lichen planus, and warts.

Product-Specific Criteria (by product)

Product-Specific Employer & Individual/Family Criteria (by product)

Approve when the product-specific trial or intolerance criteria are met (per plan type).

Fabior (tazarotene 0.1% foam) / tazarotene 0.1% foam

Acne Vulgaris
- Patient has tried and is unable to take ONE of generic tazarotene cream OR gel.
- Patient has tried and experienced inadequate efficacy or significant intolerance with one topical tretinoin-containing product.
Plaque Psoriasis
- Approve if the patient has tried and cannot take one of tazarotene cream (Tazorac cream, generics) OR gel (Tazorac gel, generics).
Treatment of Other Non-Cosmetic Conditions
- Approve if the patient has tried and cannot take ALL of the following: (A) tazarotene gel or cream; (B) adapalene cream, 0.3% gel, lotion, or solution [may require prior authorization]; (C) tretinoin cream, gel, or microgel [may require prior authorization].

Tazorac products (0.05% cream, 0.1% cream, 0.05% gel, 0.1% gel)

Brand Tazorac 0.05% cream (effective 2026-01-01)
- Patient has tried the bioequivalent generic product, tazarotene 0.05% cream, AND cannot take due to a formulation difference in inactive ingredients (e.g., dyes, fillers, preservatives) between the Brand and the bioequivalent generic product which would result, per the prescriber, in a significant allergy or serious adverse reaction.
Tazorac 0.1% cream / Tazorac 0.05% gel / Tazorac 0.1% gel
- Patient has tried the bioequivalent generic product of the same strength AND cannot take due to formulation differences in inactive ingredients which would result, per the prescriber, in a significant allergy or serious adverse reaction.

Conditions Not Covered

Tazarotene products considered not medically necessary for other uses.

ALL of the following

Cosmetic conditions: not covered (excluded from coverage in a typical pharmacy benefit).
Examples of cosmetic conditions include actinic purpura, age spots (liver spots, solar lentigines), 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, and wrinkles.

Applicable Products / Codes

Products listedmixedCovered

Arazlo	tazarotene 0.045% lotion (Bausch Health) - listed product covered with criteria
Fabior	tazarotene 0.1% foam (Mayne Pharma) - listed product covered with criteria
Tazorac	tazarotene 0.05% cream, 0.05% gel, 0.1% cream, 0.1% gel (Allergan) - listed product covered with criteria

Products listedmixedCovered

Arazlo	tazarotene 0.045% lotion (Bausch Health) - listed product covered with criteria
Fabior	tazarotene 0.1% foam (Mayne Pharma) - listed product covered with criteria
Tazorac	tazarotene 0.05% cream, 0.05% gel, 0.1% cream, 0.1% gel (Allergan) - listed product covered with criteria

Products listedmixedCovered

Arazlo	tazarotene 0.045% lotion (Bausch Health) - listed product covered with criteria
Fabior	tazarotene 0.1% foam (Mayne Pharma) - listed product covered with criteria
Tazorac	tazarotene 0.05% cream, 0.05% gel, 0.1% cream, 0.1% gel (Allergan) - listed product covered with criteria

Provider Actions

Prior Authorization

Prior Authorization Required

Prior Authorization is required for benefit coverage of topical tazarotene products; approvals provided for 1 year when criteria are met.

Documentation Required

Treatment Trials / Intolerance Documentation

Provider must document prior trials and inability to take required comparator products (e.g., generic tazarotene cream/gel, adapalene, tretinoin) or document prescriber statement of inadequate efficacy or significant intolerance; for brand Tazorac, must document inability to take bioequivalent generic due to inactive-ingredient allergy/serious adverse reaction.

generic tazarotene cream or gel
adapalene (examples: adapalene cream, 0.3% gel, lotion, or solution)
tretinoin (examples: generic tretinoin cream 0.025%, 0.05%, 0.1%; gel 0.01% or 0.025%; microsphere gel 0.04% or 0.1%)
For brand Tazorac: tried the bioequivalent generic of the same strength and cannot take due to formulation differences in inactive ingredients (e.g., dyes, fillers, preservatives) causing a significant allergy or serious adverse reaction

Background

Background: Topical tazarotene products are indicated for acne vulgaris (Arazlo lotion and Fabior foam; Tazorac 0.1% for facial acne) and plaque psoriasis (Tazorac cream and gel in 0.05% and 0.1% strengths). They have been used off-label for other dermatologic conditions (examples include basal cell carcinoma, ichthyoses, cutaneous T-cell lymphoma, nail psoriasis, oral lichen planus, warts, and others). Cosmetic uses (e.g., treatment of wrinkles, photo-aged or photo-damaged skin, age spots, stretch marks, skin laxity, and similar) are excluded from coverage.

Preferred product criteria: Product-specific trial or intolerance requirements as listed in product-specific criteria tables (e.g., trial of generic tazarotene or other topical retinoids).

Revision History

2025-12-15revisedLatest

Annual revision: policy title updated from 'Topical Tazarotene Products' to 'Topical Retinoids - Tazarotene Products'; added standardized approval language for Acne Vulgaris, Plaque Psoriasis, and Other Non-Cosmetic Conditions: 'Approve for 1 year when Preferred product criteria are met for the products listed in the below table(s)'.

2025-12-15added

Preferred Product Table language updated to add standardized approval text: 'Approve for 1 year when Preferred product criteria are met for the products listed in the below table(s)' for FDA-approved and other supported indications.

2025-12-15removed

Formatting/content updates removed Tazorac 0.05% cream and 0.1% cream from prior table formatting/locations.

Policy Summary

PayerCigna

PolicyTopical Retinoids - Tazarotene Products

Policy CodePolicy IP0174

Change TypeTitle updatePreferred table language added

Effective DateDec 15, 2025

Next Review Date

Key ActionPrior Authorization is required; approvals are provided for 1 year when criteria are met and providers must document prior trials or intolerance to required comparator products.

SourceLink

On This Page

OpenPayer

Topical Retinoids - Tazarotene Products

Coverage Summary

Initial Therapy Criteria

Product-Specific Criteria (by product)

Conditions Not Covered

Applicable Products / Codes

Provider Actions

Clinical Evidence & References

Background

Revision History