CurrentMolina HealthcarePolicy C23729-A

Vtama (tapinarof) Cream Coverage Criteria

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Coverage and prior authorization requirements for topical Vtama (tapinarof) cream for plaque psoriasis and atopic dermatitis, including diagnosis, age, clinical response, documentation, prescriber, quantity, and continuation criteria.

Policy Summary

PayerMolina Healthcare

PolicyVtama (tapinarof) Cream Coverage Criteria

Policy CodePolicy C23729-A

Change TypeRevision—no material clinical or coverage changes

Effective DateJune 11, 2026

Next Review DateApril 1, 2027

Key ActionSubmit prior authorization requests with the applicable indication-specific criteria, age restrictions, prescriber qualifications, quantity limits, pharmacy-benefit setting, and authorization duration.

SourceLink

POLICY UPDATE CHANGES

The Q2 2026 revision lists updates to Required Medical Information, Duration of Approval, Appendix, and References.

2Covered indications

18+Plaque psoriasis minimum age

2+Atopic dermatitis minimum age

6 monthsInitial authorization

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CurrentMolina HealthcarePolicy C23729-A

Vtama (tapinarof) Cream Coverage Criteria

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Policy Summary

PayerMolina Healthcare

PolicyVtama (tapinarof) Cream Coverage Criteria

Policy CodePolicy C23729-A

Change TypeRevision—no material clinical or coverage changes

Effective DateJune 11, 2026

Next Review DateApril 1, 2027

SourceLink

POLICY UPDATE CHANGES

The Q2 2026 revision lists updates to Required Medical Information, Duration of Approval, Appendix, and References.

2Covered indications

18+Plaque psoriasis minimum age

2+Atopic dermatitis minimum age

6 monthsInitial authorization

12 monthsContinuation authorization

60 or 180 g/30 daysQuantity limit

Coverage Criteria

Plaque Psoriasis Initial Therapy

Covered for plaque psoriasis when ALL of the following are met:

Plaque psoriasis initial therapy

Diagnosis and disease extent: The member has a documented diagnosis of plaque psoriasis, is 18 years of age or older, and the treatment area is no more than 20% of body surface area (BSA).Age ≥18 years; treatment area ≤20% BSA
Document the diagnosis, age, and affected BSA.
Topical corticosteroid requirement or exception: Document inadequate response, serious side effects, contraindication, or clinical rationale that topical corticosteroids are inappropriate; OR document that plaque psoriasis involves sensitive or functionally significant areas, including the face, neck, hands, feet, or genitals.One pathway required
Either the topical corticosteroid pathway or the sensitive/functionally significant area pathway must be documented.
Additional topical therapy prerequisite: Document inadequate response, serious side effects, contraindication, or clinical rationale that ONE of the following is inappropriate: tacrolimus, pimecrolimus, calcipotriene, or tazarotene.One of four agents
One additional topical therapy is required.
Prescriber and baseline documentation: Vtama is prescribed by or in consultation with a qualified specialist, and the prescriber documents baseline disease activity evaluation and treatment goals for evaluating efficacy at renewal.Prescriber qualification; baseline evaluation and goals
Submit consultation notes when prescribed in consultation.

Atopic Dermatitis Initial Therapy

Covered for atopic dermatitis when ALL of the following are met:

Atopic dermatitis initial therapy

Diagnosis and age: The member has a documented diagnosis of moderate to severe chronic atopic dermatitis (eczema) and is 2 years of age or older.Age ≥2 years; moderate to severe chronic atopic dermatitis
Document the diagnosis, chronicity, severity, and age.
Prior topical therapy
- Listed topical option: A topical corticosteroid.
- Listed topical option: Tacrolimus, a preferred/formulary topical calcineurin inhibitor.

Continuation Therapy

Continuation therapy is covered when ALL of the following are met:

Continuation therapy

Adherence is at least 85% of the time as verified by the prescriber or medication fill history; OR adherence is below 85% because surgery or treatment of an infection caused a temporary discontinuation.≥85% unless qualifying temporary interruption
Document adherence or the qualifying reason for temporary discontinuation.
Tolerability: The prescriber attests, or clinical review confirms, that there is no evidence of intolerable adverse effects or drug toxicity.No intolerable adverse effects or drug toxicity
Clinical response: Documentation shows a positive clinical response demonstrated by low disease activity and/or improvement in signs and symptoms, such as reduced affected BSA, improved severity of eczematous lesions, or decreased pruritus severity.

Uses of Vtama (tapinarof) other than its labeled indications are considered experimental/investigational and are subject to Molina’s Off-Label policy.

Clinical and Quantity Coding Details

Plaque psoriasis treatment area

Maximum affected areaNo more than 20% of body surface area (BSA)

IndicationPlaque psoriasis

DocumentationThe treatment area must be documented as a percentage of BSA

Quantity threshold by affected body surface area

Affected BSA below 10%Maximum 60 grams per 30 days

Affected BSA at or above 10%Maximum 180 grams per 30 days

ProductVtama (tapinarof) cream

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization and Coverage Limits

Prior authorization is required for Vtama (tapinarof) cream. Coverage is subject to the indication-specific criteria, age requirements, approval durations, quantity limits, and prescriber requirements below.

Plaque psoriasis: member must be at least 18 years old.
Atopic dermatitis: member must be at least 2 years old.
Initial authorization is approved for 6 months; continuation of therapy is approved for 12 months, subject to applicable Illinois and Texas Marketplace rules.
Quantity limit: affected BSA <10% — maximum 60 grams per 30 days; affected BSA ≥10% — maximum 180 grams per 30 days.
The drug must be prescribed by or in consultation with a board-certified dermatologist, allergist, or immunologist. Consultation notes must accompany initial and reauthorization requests.
Topical Vtama is recommended for pharmacy benefit coverage and patient self-administration.

Policy Background

Vtama (tapinarof) is a topical medication covered for plaque psoriasis in adults and for atopic dermatitis in adults and pediatric patients 2 years of age and older. This policy establishes the clinical, age, prior-treatment, documentation, quantity, and continuation requirements for coverage and prior authorization. Initial use is evaluated according to the applicable indication-specific criteria, and continued coverage requires documented adherence, tolerability, and positive clinical response.

Clinical Definitions and Measures

Adult fingertip unit

DefinitionThe amount of cream extending from the distal interphalangeal joint to the fingertip

Approximate quantityApproximately 0.5 grams

Application-area equivalenceAn area equal to two adult palms

BSA

Estimation methodEstimate BSA using anatomic body regions and the adult rule of nines

Palmar hand approximationThe palmar hand surface is approximately 1% of BSA

UseThe rule of nines provides a rough adult estimate of affected BSA

Initial Authorization Criteria

Plaque Psoriasis Initial Authorization

Initial authorization for plaque psoriasis requires ALL applicable criteria:

Plaque psoriasis initial authorization

Diagnosis, age, and disease extent: The member has a documented diagnosis of plaque psoriasis, is 18 years of age or older, and the treatment area is no more than 20% of BSA.Age ≥18 years; ≤20% BSA
Topical corticosteroid requirement or exception: Document inadequate response, serious side effects, contraindication, or clinical rationale that topical corticosteroids are inappropriate; OR document involvement of sensitive or functionally significant areas such as the face, neck, hands, feet, or genitals.One pathway required

Continuation Authorization Criteria

Vtama Continuation Authorization

Continuation authorization requires ALL of the following:

Vtama continuation authorization

Adherence is at least 85% as verified by the prescriber or medication fill history; OR adherence is below 85% because surgery or treatment of an infection caused temporary discontinuation.≥85% unless qualifying temporary interruption
Document adherence or the qualifying reason for temporary discontinuation.
Tolerability: There is no evidence of intolerable adverse effects or drug toxicity, as attested by the prescriber or determined by clinical review.No intolerable adverse effects or drug toxicity
Positive clinical response:

Prerequisite Treatment Requirements

Step	Therapy requirement	Acceptable documentation
1
Topical corticosteroids
Document inadequate response, serious side effects, contraindication, or clinical rationale that topical corticosteroids are inappropriate. This requirement may be satisfied when plaque psoriasis involves sensitive or functionally significant areas, such as the face, neck, hands, feet, or genitals.

Step	Therapy requirement	Acceptable documentation
1
Two listed topical therapies
For moderate to severe chronic atopic dermatitis, document inadequate response, serious side effects, or contraindication to two of the following: topical corticosteroids or preferred/formulary topical calcineurin inhibitors (tacrolimus or pimecrolimus).
Non-formulary or non-preferred product
Document trial and failure or serious side effects to a majority of preferred formulary or PDL alternatives for the diagnosis, not more than three. Include the medication(s) tried, trial dates, and reasons for treatment failure.

Quantity Limits and Dosing Guidance

Vtama (tapinarof) cream

ProductVtama (tapinarof) cream

Affected BSA thresholdLess than 10%

Maximum quantity60 grams per 30 days

Vtama (tapinarof) cream

ProductVtama (tapinarof) cream

Affected BSA thresholdAt least 10%

Maximum quantity180 grams per 30 days

Site of Care and Administration

Billing Rule

Use pharmacy benefit and home self-administration

Vtama is a topical medication recommended for pharmacy benefit coverage and patient self-administration at home.

Use the pharmacy benefit setting.
The patient self-administers the topical medication.

Policy Summary

PayerMolina Healthcare

PolicyVtama (tapinarof) Cream Coverage Criteria

Policy CodePolicy C23729-A

Change TypeRevision—no material clinical or coverage changes

Effective DateJune 11, 2026

Next Review DateApril 1, 2027

SourceLink

On This Page

Listed topical option: Pimecrolimus, a preferred/formulary topical calcineurin inhibitor.

Baseline disease activity: The prescriber documents a baseline assessment of disease activity, such as affected BSA, severity of eczematous lesions, or pruritus.Baseline disease-activity assessment

Required.

Formulary status

Preferred product pathway: The requested product is formulary or preferred.
Non-formulary/non-preferred pathway: The requested product is non-formulary or non-preferred and the required preferred formulary or PDL alternative documentation is submitted.
Document medications tried, trial dates, and reasons for treatment failure or serious side effects.

Prescriber: Vtama is prescribed by or in consultation with a qualified specialist.Prescriber qualification

Submit consultation notes when prescribed in consultation.

Positive clinical response

Prescriber: Continuation is prescribed by or in consultation with a qualified specialist.Prescriber qualification

Submit consultation notes with reauthorization requests when prescribed in consultation.

Continuation adherence

Minimum adherenceAt least 85% of the time, verified by the prescriber or medication fill history

Temporary discontinuation exceptionAdherence below 85% is permitted when surgery caused the temporary discontinuation

Additional exceptionAdherence below 85% is permitted when treatment of an infection caused the temporary discontinuation

Suggested monthly quantity per affected body surface area

Suggested quantity10 grams per month for each 1% of affected BSA

Basis of estimateApproximately 0.25 grams per application over 1% BSA, using 40 applications per month

Application frequency used in estimateOnce-daily application

Pivotal plaque psoriasis trial affected BSA

Affected BSA range3% to 20% of total affected BSA

PopulationAdults with mild to severe chronic plaque psoriasis

TrialsPSOARING 1 and PSOARING 2

Pivotal plaque psoriasis trial baseline PGA

Baseline PGA range2 (mild) to 4 (severe)

Assessment scale5-point scale from 0 to 4

Severity directionHigher scores indicate more severe psoriasis

Atopic dermatitis treatment success

Treatment-success scorevIGA-AD score of Clear (0) or Almost Clear (1)

Required improvementAt least a 2-grade improvement from baseline

AssessmentValidated 5-point Investigator's Global Assessment for atopic dermatitis

Atopic dermatitis pruritus endpoint

Pruritus improvementAt least a 4-point improvement in PP-NRS score

Applicable ageSubjects 12 years of age and older

ConditionAtopic dermatitis

Billing Rule

Illinois Prior Authorization Duration

For an Illinois Marketplace recurring health care service or maintenance medication used to treat a chronic or long-term condition, an approved prior authorization remains valid for the lesser of 12 months from the date the provider receives approval or the length of treatment determined by the treating health care professional.

This rule does not apply to benzodiazepines or Schedule II narcotic drugs, including opioids.
The rule does not require coverage of care or services completely excluded from the policy's covered benefits, except as required by applicable medical-exception processes.

Documentation Required

Illinois Medical Exceptions

Do not deny an Illinois off-formulary exception request when a qualifying medical-exception condition is documented.

The formulary drug is contraindicated.
The member tried the formulary drug under the current or a previous health plan and the prescribing provider submits evidence of failure or intolerance.
The member is stable on a drug selected by the treating provider for the condition while covered by the current or a previous health plan.
When granted, the exception must authorize the prescribed covered drug up to the quantity covered. Approval must be honored for 12 months after approval or until plan renewal.

Unsupported block type: billing_rule

Step Therapy

Plaque Psoriasis Prerequisite Therapy

For plaque psoriasis, document inadequate response, serious side effects, contraindication, or clinical rationale that topical corticosteroids are inappropriate, unless the disease involves sensitive or functionally significant areas.

Sensitive or functionally significant areas include, for example, the face, neck, hands, feet, or genitals.
Also document inadequate response, serious side effects, contraindication, or clinical rationale of inappropriateness to ONE of tacrolimus, pimecrolimus, calcipotriene, or tazarotene.
The prescriber must document baseline disease activity and treatment goals for evaluation at renewal.

Step Therapy

Atopic Dermatitis Prerequisite Therapy

For moderate to severe chronic atopic dermatitis, document inadequate response, serious side effects, or contraindication to TWO of the following: topical corticosteroids or preferred/formulary topical calcineurin inhibitors (tacrolimus or pimecrolimus).

The prescriber must document baseline disease activity, such as affected BSA, severity of eczematous lesions, or pruritus.
For a non-formulary or non-preferred product, document trial and failure of or serious side effects to a majority, not more than three, of the preferred formulary or PDL alternatives.

Documentation Required

Medical Records and Supporting Documentation

Molina may require additional documentation for coverage determination, quality improvement, and fraud, waste, and abuse prevention. Submit sufficient records to support the requested therapy and the provider's clinical decision.

Patient medical records and relevant test results.
Credentials of the provider ordering or performing the drug or service.
Additional supporting materials requested for case-by-case review.

Documentation Required

Member-Specific Clinical Data

When the requested product is dosed by weight, body surface area, or another member-specific measurement, submit the applicable data element as part of the medical-necessity review, along with the member's complete relevant medical history.

Document the member's affected body surface area when relevant to dosing or quantity limits.
Provide other required member-specific measurements, including weight or BSA when applicable.
Include complete relevant medical history and any additional information needed for adequate review.

Documentation Required

Non-Preferred Product Documentation

For a requested non-formulary or non-preferred product, document the member's experience with preferred formulary or PDL alternatives.

List each medication tried.
Provide the date or dates of each trial.
Explain the reason for treatment failure, intolerance, or serious side effects.
Document the applicable majority of preferred alternatives, not more than three, for the diagnosis.

Documentation Required

Specialist Consultation Notes

When Vtama is prescribed in consultation with a board-certified dermatologist, allergist, or immunologist, submit the consultation notes with both the initial request and each reauthorization request.

The prescribing provider or consulting specialist must be a board-certified dermatologist, allergist, or immunologist.
Consultation notes are required for initial authorization and reauthorization.

Documentation Required

Clinical Criteria Documentation

Document the clinical criteria supporting the requested indication and treatment. The record must establish the diagnosis, disease extent or activity, prior treatment experience, and clinical appropriateness of Vtama.

Plaque psoriasis: documented diagnosis and treatment area of ≤20% BSA.
Atopic dermatitis: documented diagnosis of moderate to severe chronic atopic dermatitis.
Document disease activity or extent, including affected BSA, severity of lesions, pruritus, or other relevant findings.
Document inadequate response, intolerance, serious side effects, contraindications, or clinical inappropriateness of required prerequisite therapies.
For continuation, document adherence, absence of intolerable adverse effects or drug toxicity, and positive clinical response such as lower disease activity or improved signs and symptoms.

Documentation Required

Document Formulary Failure or Intolerance

For an Illinois medical exception based on prior formulary failure or intolerance, submit evidence that the member tried the formulary drug under the current or a previous health plan and that the drug failed or was not tolerated.

Identify the formulary medication tried.
Provide evidence of treatment failure or intolerance from the prescribing provider.
If the member is stable on a provider-selected drug, document that stability under the current or previous health plan.

Denial Risk

Unsupported Medical Necessity or Documentation

Molina may deny reimbursement or take other appropriate action when submitted documentation does not support medical necessity, non-investigational status, benefit eligibility, or other applicable requirements, or when it indicates inappropriate or excessive billing or other practice.

Documentation must support that the drug or service is medically necessary.
Documentation must support that the drug or service is not investigational or experimental.
Documentation must support that the request is within the member's covered benefits and otherwise meets applicable requirements.
Inadequate, incomplete, or concerning documentation may create denial or non-reimbursement risk.

Denial Risk

Initial Criteria Not Met

An initial authorization may be denied when the request does not meet the required indication, age, disease extent, prerequisite-therapy, prescriber, or documentation criteria.

Plaque psoriasis does not meet the documented diagnosis or ≤20% BSA treatment-area requirement.
Atopic dermatitis is not documented as moderate to severe chronic disease, or the required topical-therapy history is absent.
The member does not meet the indication-specific minimum age: 18 years for plaque psoriasis or 2 years for atopic dermatitis.
Required baseline disease activity, treatment goals, prior-treatment response or intolerance, contraindication, or clinical-appropriateness documentation is missing.
The prescriber or required specialist consultation does not meet the stated requirements.
The requested quantity exceeds the applicable BSA-based limit.

Denial Risk

Continuation Criteria Not Met

Continuation authorization may be denied when the member does not demonstrate the required adherence, tolerability, or positive clinical response.

Adherence is below 85% without the permitted temporary interruption for surgery or infection treatment.
The prescriber cannot attest, or clinical review finds, intolerable adverse effects or drug toxicity.
The record does not document positive clinical response, such as low disease activity or improvement in affected BSA, lesion severity, pruritus, or other signs and symptoms.

Denial Risk

Off-Label Use

Uses of Vtama (tapinarof) outside its labeled indications are considered experimental or investigational and are subject to Molina's Off-Label policy.

The policy lists no labeled contraindications to Vtama.
Requests for non-labeled use must be evaluated under Molina's Off-Label policy.

Physician Global Assessment (PGA)

0 — ClearNo signs of psoriasis; post-inflammatory hyperpigmentation may be present

1 — Almost clearNo thickening; normal to pink coloration; no to minimal focal scaling

2 — MildJust detectable to mild thickening; pink to light red coloration; predominantly fine scaling

3 — ModerateClearly distinguishable to moderate thickening; dull to bright red, clearly distinguishable erythema; moderate scaling

4 — SevereSevere thickening with hard edges; bright to deep dark red coloration; severe or coarse scaling covering almost all or all lesions

Body surface area (BSA)

DefinitionPercentage of total skin surface affected by psoriasis

Mild diseaseLess than 3% BSA

Moderate disease3% to 10% BSA

Severe diseaseMore than 10% BSA

Physician Global Assessment (PGA)

Assessment formatA 5-point assessment of overall psoriasis severity

Clinical featuresBased on erythema, scaling, and plaque thickness

Score interpretationHigher scores indicate more severe disease

Trial baseline rangeScores of 2 to 4 in the pivotal trials

vIGA-AD

MeaningInvestigator's Global Assessment for atopic dermatitis

Treatment successClear (0) or Almost Clear (1)

Required changeAt least a 2-grade improvement from baseline

Additional topical prerequisite:

Document inadequate response, serious side effects, contraindication, or clinical rationale that ONE of tacrolimus, pimecrolimus, calcipotriene, or tazarotene is inappropriate.

Prescriber and baseline goals: The medication is prescribed by or in consultation with a qualified specialist, and the prescriber documents baseline disease activity evaluation and treatment goals for evaluating efficacy at renewal.Baseline evaluation and goals

Initial authorization duration is 6 months; submit consultation notes when applicable.

Atopic Dermatitis Initial Authorization

Initial authorization for atopic dermatitis requires ALL applicable criteria:

Atopic dermatitis initial authorization

Diagnosis and age: The member has a documented diagnosis of moderate to severe chronic atopic dermatitis (eczema) and is 2 years of age or older.Age ≥2 years; moderate to severe chronic disease
Prior topical therapy
- Listed option: A topical corticosteroid.
- Listed option: Tacrolimus, a preferred/formulary topical calcineurin inhibitor.
- Listed option: Pimecrolimus, a preferred/formulary topical calcineurin inhibitor.
Baseline disease activity: The prescriber documents a baseline assessment of disease activity, such as affected BSA, severity of eczematous lesions, or pruritus.Baseline assessment
Formulary status requirement
- Preferred pathway: The requested product is formulary or preferred.
- Non-preferred pathway: The requested product is non-formulary or non-preferred and the required alternative-therapy documentation is submitted.
Prescriber: The medication is prescribed by or in consultation with a qualified specialist.Prescriber qualification
Initial authorization duration is 6 months; submit consultation notes when applicable.

The member demonstrates positive clinical response, shown by low disease activity and/or improvement in signs and symptoms, including reduction of affected BSA, improvement in severity of eczematous lesions, or decreased pruritus severity.

Positive clinical response

Prescriber: Continuation is prescribed by or in consultation with a qualified specialist.Prescriber qualification

Continuation authorization duration is 12 months; submit consultation notes with reauthorization requests when applicable.

Vtama (tapinarof) cream

ProductVtama (tapinarof) cream

Suggested quantity10 grams per month for each 1% of affected BSA

CalculationAffected BSA percentage multiplied by 10 grams per month

Vtama (tapinarof) cream

Affected BSA9%

Suggested monthly quantity90 grams per month

Calculation9% BSA × 10 grams per 1% BSA per month

Vtama (tapinarof) cream

Affected BSA18%

Suggested monthly quantity180 grams per month

Calculation18% BSA × 10 grams per 1% BSA per month