CurrentMass General Brigham Health PlanPolicy N/A

Vtama (tapinarof) 1% cream — Prior Authorization and Coverage Criteria

This policy defines prior authorization, coverage criteria, quantity limits, and continuation requirements for Vtama (tapinarof) 1% cream for treatment of plaque psoriasis in adults for Mass General Brigham Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyVtama (tapinarof) 1% cream — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Vtama 1% cream; approvals granted up to 6 months with a quantity limit of 60 g per 30 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum patient age for coverage

60 g/30dquantity limit for Vtama 1% cream

6 moapproval length

90 dcontinuity allowance window

Coverage Criteria for Vtama (tapinarof) 1% cream

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Initial Authorization

Authorization may be granted when ONE of the following pathways is met:

Pathway A - Continuity: Member is new to the plan within the past 90 days and currently receiving treatment with the requested medication (continuity allowance)90 days

Continuity allowance does not apply when the product was obtained only as samples or via manufacturer's patient assistance programs.

Pathway B - Diagnosis-specific: Member is 18 years of age or older AND has a diagnosis of plaque psoriasis AND has had inadequate treatment response, intolerance, or contraindication to a topical steroid AND the medication will be used on a sensitive skin area (face, genitals, or skin folds)age >=18

diagnosis and prior therapy requirements

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage under the pharmacy benefit. Initial approvals and reauthorizations are granted for up to 6 months. Quantity limits apply: Vtama (tapinarof) 1% cream — 60 grams per 30 days. Authorization may be granted for members new to the plan within the past 90 days who are currently receiving the requested medication (excludes samples or manufacturer patient assistance programs).

Pharmacy benefit: Prior authorization required
Initial and reauthorization approval duration: up to 6 months
Quantity limit: Vtama 1% cream — 60 g per 30 days

Step Therapy

Step / Criteria Alternatives

Authorization may be granted when ALL of the following are met: the member is 18 years or older; the member has a diagnosis of plaque psoriasis; and the member has had an inadequate response to, intolerance of, or contraindication to a topical steroid. Alternatively, approval may be granted when the medication will be used on a sensitive skin area (e.g., face, genitals, or skin folds).

Age requirement: ≥ 18 years
Diagnosis: plaque psoriasis
Prior therapy: inadequate response, intolerance, or contraindication to a topical corticosteroid
Sensitive area use qualifies as an alternative criterion

Documentation Required

Reauthorization Documentation

Reauthorization requires physician documentation demonstrating improvement in the member's condition. Clinical notes should describe objective or subjectively meaningful improvement attributable to therapy. Failure to provide adequate documentation may result in denial of the request.

Documentation required: physician progress notes describing improvement
Operational note: inadequate documentation may trigger denial at reauthorization

Denial Risk

Denial Triggers

Requests may be denied if the member is under 18 years of age, lacks a diagnosis of plaque psoriasis, has not tried or cannot document prior inadequate response/intolerance/contraindication to a topical steroid when required, if the request exceeds quantity limits, or if required documentation (including for reauthorization) is not provided. New-member continuity approvals exclude therapy obtained via samples or manufacturer's patient assistance programs.

Denial triggers: age <18
Denial triggers: diagnosis not plaque psoriasis
Denial triggers: missing prior therapy documentation or inappropriate step criteria
Denial triggers: exceeding quantity limit (60 g/30 days)
Denial triggers: insufficient reauthorization documentation
Denial triggers: therapy previously obtained only as samples or via patient assistance

Definitions and Drug Description

Vtama (tapinarof) 1% cream — description and indication

Drug class and formulationTapinarof 1% cream — an aryl hydrocarbon receptor agonist (topical formulation)

IndicationTopical treatment of plaque psoriasis in adults

Age populationAdults (18 years and older) per policy criteria

Supporting evidencePolicy references phase 3 trials and clinical guideline literature (see references)

Sensitive skin areas — policy definition

DefinitionSensitive skin areas include the face, genitals, or skin folds as specified by the policy

Example — faceIncludes facial skin where topical therapy may require alternative consideration

Example — genitalsIncludes genital skin where topical therapy may require alternative consideration

Example — skin foldsIncludes intertriginous areas (skin folds) where sensitivity is increased

OpenPayer

Vtama (tapinarof) 1% cream — Prior Authorization and Coverage Criteria

Coverage Criteria for Vtama (tapinarof) 1% cream

Relevant Codes and Quantity Limits

Provider Requirements, Prior Authorization, and Documentation

Definitions and Drug Description

Background