CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Medicaid_Vtama_ 20250210

Coverage and prior authorization criteria for Vtama (tapinarof) cream for plaque psoriasis (adults) and atopic dermatitis (ages 2+) including initial and continuation authorization, concomitant therapy exclusions, and quantity limits for Neighborhood Health Plan of Rhode Island Medicaid.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Vtama_ 20250210

Policy CodePolicy N/A

Change TypeReview (no material change)

Effective Date

Next Review Date

Key ActionFor initial authorization, document age, diagnosis, BSA affected, specialist prescribing or consultation, prior treatment trials (durations and inadequacy or intolerance), and any contraindications/adverse effects as specified in the criteria.

SourceLink

POLICY UPDATE CHANGES

Last Reviewed dates include 9/2022, 6/2023, 5/2024, 2/2025

2Covered Indications

60 gQuantity limit

12 moAuth duration

>=2Min age for AD

Coverage Summary

Coverage and prior authorization criteria for Vtama (tapinarof) cream apply to its FDA-approved indications: plaque psoriasis in adults and atopic dermatitis in patients aged 2 years and older. Coverage is limited to FDA-approved indications and is provided only when all applicable approval criteria are met and no exclusions to the prescribed therapy exist.

Policy Thresholds (key values)

Plaque Psoriasis BSA3-20% BSA affected

Atopic Dermatitis minimum age>= 2 years

Topical corticosteroid trial duration (psoriasis)2-4 consecutive weeks

Topical calcineurin/Eucrisa trial durations (AD)Tacrolimus or pimecrolimus: 6 consecutive weeks; Eucrisa: 4 consecutive weeks

Zoryve trial windowWithin the last 12 months

Quantity limit60 grams per 30 days

Plaque Psoriasis — Initial Authorization (12 months)

Plaque Psoriasis - Initial Authorization (12 months)

Covered when ALL of the following are met:

ALL of the following

Member is 18 years of age or older, diagnosed with plaque psoriasis
Documentation of BSA affected is provided: Documentation of affected area(s) and that the affected body surface area (BSA) is between 3-20%3-20% BSA affected
Documentation of BSA affected is provided
Vtama is prescribed by, or in consultation with, a specialist in dermatology or rheumatology
Documentation that the member experienced an inadequate treatment response to at least a 2-4 consecutive week trial within the last 12 months of a high or super-high potency topical corticosteroid (e.g., augmented betamethasone, clobetasol).2-4 consecutive weeks
Contraindications, adverse effects and/or intolerance must be documented.
Inadequate response or intolerance to TWO of the following therapies within the last 12 months (in combination with a topical corticosteroid):
- Topical calcineurin inhibitors (e.g., tacrolimus ointment, pimecrolimus cream)
- Topical vitamin D analogs (e.g., calcipotriene 0.005% ointment, cream, solution)
- Topical retinoid (e.g., tazarotene cream 0.1%)
- Phototherapy
- Oral systemic non-biologic drugs (e.g., methotrexate, cyclosporine, or acitretin)
Documentation that the member experienced an inadequate treatment response or intolerance from Zoryve (roflumilast) cream 0.3% within the last 12 months.Within the last 12 months
Contraindications, adverse effects and/or intolerance must be documented. If switching from a biologic for psoriasis treatment, trial of Zoryve is not required
Concomitant use excluded: Vtama will not be used concomitantly with Zoryve (roflumilast) cream, any therapeutic biologic drug (e.g., adalimumab, infliximab), or any targeted synthetic drug (e.g., apremilast).

Prior Authorization

Initial prior authorization required with documentation

Initial prior authorization is required. Provider must document the member's age, the diagnosis, the affected body surface area (BSA), that Vtama was prescribed by or in consultation with an appropriate specialist, prior treatment trials with durations and documentation of inadequate response or intolerance, and any contraindications or adverse effects.

Age
Diagnosis
Documentation of affected BSA
Specialist prescribing or consultation (dermatology, rheumatology, or allergy/immunology as applicable)
Prior treatment trials with durations and reason for failure/intolerance (see indication-specific requirements)
Documentation of contraindications, adverse effects, or intolerance

Billing Rule

Quantity limit enforcement

Vtama cream 1% is limited to 60 grams per 30 days. Claims exceeding this quantity may be denied or may require additional justification/documentation.

Atopic Dermatitis — Initial Authorization (12 months)

Atopic Dermatitis - Initial Authorization (12 months)

Covered when ALL of the following are met:

ALL of the following

Member is 2 years of age or older>= 2 years
Vtama is prescribed by, or in consultation with, a specialist in dermatology or allergy/immunology
Documentation of BSA affected is provided: Member has a diagnosis of atopic dermatitis (AD)
Documentation of BSA affected is provided
Documentation that member experienced an inadequate treatment response or intolerance to at least one medium to super-high potency topical corticosteroid for at least 2 consecutive weeks.at least 2 consecutive weeks
Contraindications, adverse effects and/or intolerance must be documented.
Inadequate response or intolerance to one of the following formulary topical drugs:
- Tacrolimus ointment for 6 consecutive weeks6 consecutive weeks
- Pimecrolimus cream for 6 consecutive weeks6 consecutive weeks
- Eucrisa (crisaborole) ointment for 4 consecutive weeks4 consecutive weeks
For members 6 years of age or older with mild to moderate disease:
- Documentation that the member experienced an inadequate treatment response or intolerance from Zoryve (roflumilast) cream 0.15% within the last 12 monthsWithin the last 12 months
Concomitant use excluded: Vtama will not be used concomitantly with Eucrisa (crisaborole) ointment, Opzelura (ruxolitinib) cream, Zoryve (roflumilast) cream, any therapeutic biologic drug or any targeted synthetic drug

Prior Authorization

Atopic dermatitis — initial prior authorization documentation

For atopic dermatitis (AD) initial authorization, provider must document the member's age (≥2 years), the AD diagnosis, affected BSA, that Vtama was prescribed by or in consultation with a specialist, prior topical corticosteroid and formulary topical trials with durations and documentation of inadequate response or intolerance, and any contraindications/adverse effects.

Age (member is 2 years of age or older)
Diagnosis of atopic dermatitis and documentation of affected BSA
Specialist prescribing or consultation (dermatology or allergy/immunology)
Prior inadequate response or intolerance to at least one medium to super-high potency topical corticosteroid for ≥2 consecutive weeks
Prior inadequate response or intolerance to one formulary topical: tacrolimus 6 weeks, pimecrolimus 6 weeks, or Eucrisa 4 weeks
Documentation of contraindications, adverse effects, or intolerance

Continuation of Therapy (Renewal — 12 months)

Continuation of Therapy (12 months)

Authorization may be renewed when ALL of the following are met:

ALL of the following

ALL of the following
- One of the following demonstrates improvement:
  - Reduction in body surface area (BSA) affected from baseline
  - Improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling, burning, cracking, pain, clear or almost clear skin)
Concomitant use excluded: Vtama will not be used concomitantly with Zoryve (roflumilast) cream, Eucrisa (crisaborole) ointment, Opzelura (ruxolitinib) cream, any therapeutic biologic drug (e.g., adalimumab, infliximab) or any targeted synthetic drug (e.g., apremilast, upadacitinib).

Prior Authorization

Continuation authorization requirements

For continuation (renewal) authorization, provider must document a positive clinical response demonstrated by reduction in BSA affected from baseline or improvement in signs and symptoms, and confirm ongoing absence of excluded concomitant therapies.

Evidence of positive clinical response: reduction in BSA from baseline or improvement in signs/symptoms (e.g., itching, redness, scaling, clear or almost clear skin)
No concomitant use of excluded therapies (see policy list)

Concomitant Therapy Exclusions and Not Covered Uses

Concomitant use exclusions: Vtama must not be used concomitantly with Zoryve (roflumilast) cream (both 0.3% for psoriasis and 0.15% for AD where applicable), Eucrisa (crisaborole) ointment, Opzelura (ruxolitinib) cream, any therapeutic biologic drugs (e.g., adalimumab, infliximab), or any targeted synthetic drugs (e.g., apremilast, upadacitinib). Uses outside the FDA-approved indications are considered investigational/not medically necessary.

Documentation Required

Concomitant therapy exclusion must be documented

Prescriber must ensure and document that Vtama is not used concomitantly with the policy's excluded topical agents, therapeutic biologics, or targeted synthetic drugs and record this absence in the medical record.

Document absence of concomitant use with Zoryve (roflumilast) cream, Eucrisa (crisaborole) ointment, Opzelura (ruxolitinib) cream
Document absence of concomitant use with any therapeutic biologic (e.g., adalimumab, infliximab)
Document absence of concomitant use with any targeted synthetic drug (e.g., apremilast, upadacitinib)

Revision History

2022-09review

Last Reviewed dates include 9/2022; document shows review history through 2/2025 with no specific clinical policy statement change noted.

2023-06review

Last Reviewed dates include 6/2023; document shows review history through 2/2025 with no specific clinical policy statement change noted.

2024-05review

Last Reviewed dates include 5/2024; document shows review history through 2/2025 with no specific clinical policy statement change noted.

2025-02reviewLatest

Last Reviewed dates include 2/2025; document shows review history through 2/2025 with no specific clinical policy statement change noted.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyMedicaid_Vtama_ 20250210

Policy CodePolicy N/A

Change TypeReview (no material change)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Medicaid_Vtama_ 20250210

Coverage Summary

Covered Indications (at-a-glance)

Plaque Psoriasis — Initial Authorization (12 months)

Atopic Dermatitis — Initial Authorization (12 months)

Continuation of Therapy (Renewal — 12 months)

Concomitant Therapy Exclusions and Not Covered Uses

Applicable Codes

Provider Actions & Billing Rules

Clinical Evidence & References

Background

Revision History