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