CurrentColorado Rocky Mountain Health PlansPolicy N/A

Epsolay (benzoyl peroxide) topical cream prior authorization

Defines prior authorization and medical necessity criteria for Epsolay (benzoyl peroxide) topical cream for treatment of inflammatory lesions of rosacea in adults for Colorado Rocky Mountain Health Plans members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEpsolay (benzoyl peroxide) topical cream prior authorization

Policy CodePolicy N/A

Change TypeCoverage clarification and step option update

Effective DateNov 1, 2025

Next Review DateAug 1, 2025

Key ActionObtain prior authorization documenting diagnosis of rosacea, treatment for inflammatory lesions, and failure/intolerance/contraindication to two specified topical agents after 30-day trials.

SourceLink

POLICY UPDATE CHANGES

Added that Epsolay is typically excluded from coverage.

Included brand Finacea as a required trial option.

Removed prior statement that step therapy may be in place (annual review noted).

2required topical failures

6initial authorization (mo)

12re-authorization (mo)

Adultsindicated population

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Coverage Criteria for Epsolay (benzoyl peroxide) topical cream

inv-01: Initial Authorization

Covered when ALL of the following are met

Initial Authorization: Member is an adult with a diagnosis of rosacea; treatment is for inflammatory lesions; and there is a history of failure (after a 30‑day trial), contraindication, or intolerance to two of the following topical agents: topical metronidazole cream or gel (generic Metrocream, Metrogel), Finacea (azelaic acid 15%), or Soolantra (ivermectin 1% cream).failure/intolerance/contraindication to 2 agents after 30-day trial

Authorization issued for 6 months

inv-02: Reauthorization

Covered when ALL of the following are met

Reauthorization: Documentation of positive clinical response to therapy demonstrated by a reduction in inflammatory lesion counts.clinical response documented

Authorization issued for 12 months; state mandates and member-specific benefit plans may affect coverage

Epsolay is typically excluded from coverage. Coverage may still be determined by member-specific benefit plans, state mandates, or other applicable federal regulatory requirements and utilization management programs.

Provider Requirements and Actions

Prior Authorization

Prior Authorization — Initial

Prior authorization is required for initial requests. Authorization will be issued for 6 months.

Must have a diagnosis of rosacea
Treatment must be for inflammatory lesions (papules/pustules)
Member must have trialed and failed, or have a contraindication or intolerance to TWO of the following topical therapies: topical metronidazole (cream or gel), Finacea (azelaic acid 15%), Soolantra (ivermectin 1% cream) — each trial must be at least 30 days unless contraindicated or not tolerated

Documentation Required

Required Documentation / Reauthorization

Documentation must demonstrate the diagnosis and clinical intent, and prior trials or contraindications/intolerances as required. Reauthorization approvals require documentation of a positive clinical response.

Document diagnosis of rosacea and that treatment is for inflammatory lesions

Step Therapy Requirements

Step	Required trial(s)
1	Trials of two of the following topical agents: topical metronidazole (cream or gel), Finacea (azelaic acid 15%), or Soolantra (ivermectin 1% cream). Each trial must be at least 30 days; approval requires failure, intolerance, or contraindication to two agents.

Initial Therapy

inv-10: Initial therapy approval conditions

Initial therapy approval conditions

Initial: Diagnosis of rosacea; treatment targeted to inflammatory lesions; and prior failure, intolerance, or contraindication to two of the listed topical agents after a 30‑day trial (topical metronidazole cream or gel, Finacea azelaic acid 15%, or Soolantra ivermectin 1% cream).30-day trial per agent; two agents

Initial authorization duration: 6 months

Reauthorization / Continuation Criteria

inv-11: Reauthorization — Requires documented clinical improvement.

Reauthorization requires documented clinical improvement.

Reauthorization: Documented reduction in inflammatory lesion counts demonstrating a positive clinical response to therapy.documented improvement

Reauthorization duration: 12 months; member plan or state mandates may apply

Definitions

Epsolay — Key definitions and facts

Drug nameEpsolay (benzoyl peroxide) topical cream

IndicationTreatment of inflammatory lesions of rosacea in adults

Drug classTopical benzoyl peroxide

Typical coverage stanceTypically excluded from coverage (member-specific benefit plans and state mandates may apply).

Initial authorization duration6 months (per policy initial approval note)

Background

Epsolay (benzoyl peroxide) topical cream is indicated for the treatment of inflammatory lesions of rosacea in adults. Clinical use is focused on reducing inflammatory lesion counts in adult patients with rosacea.