CurrentNeighborhood Health Plan of Rhode IslandPolicy 1486-A

Topical and oral therapies for rosacea (Emrosi/minocycline ER, Finacea, Mirvaso, Noritate, Rhofade, Soolantra)

Authorization criteria for specified rosacea medications (Emrosi [minocycline HCl ER], Finacea Gel/Foam, Mirvaso, Noritate, Rhofade, Soolantra) including indication, limitation of use, required diagnosis, symptom response requirement, and duration of approval for initial and continuation therapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical and oral therapies for rosacea (Emrosi/minocycline ER, Finacea, Mirvaso, Noritate, Rhofade, Soolantra)

Policy CodePolicy 1486-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and may be granted only when the patient has a diagnosis of rosacea and has experienced a reduction in rosacea symptoms from baseline; document baseline symptoms and improvement to support authorization.

POLICY UPDATE CHANGES

No material clinical or coverage changes were made in this update.

6Drugs listed

4 moInitial DOA

12 moEmrosi continuation

36 moOther agents continuation

Coverage Summary

Coverage stance: covered_with_criteria. Scope: authorization criteria apply to specified rosacea medications: Emrosi (minocycline HCl ER), Finacea Gel and Foam (azelaic acid), Mirvaso (brimonidine), Noritate (metronidazole), Rhofade (oxymetazoline), and Soolantra (ivermectin). Authorization requires a diagnosis of rosacea and documented symptom response (reduction in inflammatory papules/pustules and/or facial erythema) from baseline. High-level durations: initial approval 4 months for all listed drugs; Emrosi continuation 12 months; Finacea, Mirvaso, Noritate, Rhofade, and Soolantra continuation 36 months.

Initial Therapy Criteria

Authorization criteria for rosacea therapies

Authorization may be granted for the requested drug when ALL of the following are met:

ALL of the following

Diagnosis: Patient has a diagnosis of rosacea
Symptom response: Patient has experienced a reduction in symptoms of rosacea from baseline (e.g., inflammatory papules or pustules, facial erythema)
Definition: Reduction in symptoms from baseline = Clinical improvement in inflammatory papules or pustules and/or facial erythema compared to pre-treatment baseline.

Prior Authorization

Authorization required

Prior authorization is required and may be granted only when the patient has a diagnosis of rosacea and has experienced a reduction in rosacea symptoms from baseline (e.g., inflammatory papules or pustules, facial erythema).

Documentation Required

Document symptom improvement

Provider must document baseline rosacea symptoms and subsequent reduction in symptoms to support initial and continuation authorization.

Continuation Therapy Criteria

Continuation Therapy

Continuation authorization requires documentation of ongoing reduction in rosacea symptoms from baseline.

ALL of the following

Diagnosis: Patient has a diagnosis of rosacea
Ongoing symptom response: Patient has experienced and documentation confirms continued reduction in symptoms of rosacea from baseline (e.g., inflammatory papules or pustules, facial erythema)
Duration of continuation approval: Emrosi (minocycline ER) continuation DOA: 12 months; Finacea, Mirvaso, Noritate, Rhofade, Soolantra continuation DOA: 36 months.

Billing Rule

Duration of approval specified

Use specified durations when authorizing: Emrosi initial 4 months / continuation 12 months; Finacea, Mirvaso, Noritate, Rhofade, Soolantra initial 4 months / continuation 36 months.

Emrosi: initial 4 months / continuation 12 months
Finacea: initial 4 months / continuation 36 months
Mirvaso: initial 4 months / continuation 36 months
Noritate: initial 4 months / continuation 36 months
Rhofade: initial 4 months / continuation 36 months
Soolantra: initial 4 months / continuation 36 months

Provider Actions / Authorization Steps

Prior auth & documentation callouts

Unsupported block type: prior_auth

Unsupported block type: documentation

Billing rules and practical notes

Unsupported block type: billing_rule

Applicable Codes

No coding groups are provided in the brief. For claims or dispensing workflows, reference the payer's maintained NDC and billing code lists for these products (e.g., Emrosi, Finacea Gel/Foam, Mirvaso, Noritate, Rhofade, Soolantra) rather than creating an empty code table here.

Clinical Evidence & References

Evidence sources cited in the policy: Emrosi package insert — Journey Medical Corporation; November 2024. Finacea Gel and Foam package inserts — LEO Pharma Inc.; Finacea Gel November 2021, Finacea Foam December 2020. Mirvaso package insert — Galderma Laboratories; December 2022. Rhofade package insert — EPI Health, LLC; November 2019. Noritate package insert — Bausch Health US; June 2020. Soolantra package insert — Galderma Laboratories; October 2022.

Background and Indications

Background and FDA indications/limitations: Emrosi (minocycline HCl ER) is indicated for treatment of inflammatory lesions of rosacea; this formulation has not been evaluated for the treatment or prevention of infections. Finacea Gel and Finacea Foam (azelaic acid 15%) are indicated for the topical treatment of the inflammatory papules and pustules of mild to moderate rosacea; efficacy for treating erythema in the absence of papules/pustules has not been evaluated. Mirvaso (brimonidine topical gel 0.33%) is indicated for the topical treatment of persistent (nontransient) facial erythema of rosacea in adults. Noritate is indicated for topical treatment of inflammatory lesions and erythema of rosacea. Rhofade (oxymetazoline 1% cream) is indicated for topical treatment of persistent facial erythema associated with rosacea in adults. Soolantra cream is indicated for the treatment of inflammatory lesions of rosacea.

Policy operational facts

Policy Number1486-A

Last Review2024-11-01

StatusCURRENT

Drugs Listed6

Initial therapy DOA4 months (all listed drugs)