CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Acitretin Non-Oncology

Defines coverage criteria for acitretin (Soriatane) for Medicaid members for FDA-approved and specified compendial uses (severe psoriasis, lichen planus, keratosis follicularis/Darier disease) with authorization for up to 12 months when criteria are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAcitretin Non-Oncology

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2017

Next Review Date

Key ActionPrior authorization for up to 12 months is required and will be granted only if the signed patient agreement with two negative pregnancy tests (for females of reproductive potential) is documented and the diagnosis is severe psoriasis, lichen planus, or keratosis follicularis (Darier Disease).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

3Covered Indications

Coverage Summary

Scope: Defines coverage criteria for acitretin (Soriatane) for Medicaid members for FDA-approved and specified compendial uses. Coverage stance: covered with criteria when used for severe psoriasis (FDA-approved) or the compendial indications lichen planus and keratosis follicularis (Darier Disease); other uses are not covered.

Policy key facts

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