CurrentNeighborhood Health Plan of Rhode IslandPolicy 1486-A

Rosacea Topical Products: Brimonidine Gel, Ivermectin Cream

Defines authorization criteria and durations of approval for topical rosacea medications listed (Emrosi/minocycline ER, Finacea gel/foam, Mirvaso/brimonidine, Noritate/metronidazole, Rhofade/oxymetazoline, Soolantra/ivermectin) for patients with a diagnosis of rosacea.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRosacea Topical Products: Brimonidine Gel, Ivermectin Cream

Policy CodePolicy 1486-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAuthorization may be granted only when the patient has a diagnosis of rosacea and has experienced a reduction in rosacea symptoms from baseline; providers should document baseline symptoms and subsequent symptom reduction to support approval.

SourceLink

POLICY UPDATE CHANGES

No material changes — the policy contains existing authorization criteria and product listings without material clinical/coverage changes.

7Products referenced

4 mo / 12-36 moDurations (init/cont)

Coverage Summary

Defines authorization criteria and durations of approval for topical rosacea medications listed: Emrosi (minocycline ER), Finacea gel and foam (azelaic acid 15%), Mirvaso (brimonidine), Noritate (metronidazole), Rhofade (oxymetazoline), and Soolantra (ivermectin). Coverage stance: covered_with_criteria. Authorization may be granted when the patient has a diagnosis of rosacea and has experienced a reduction in rosacea symptoms from baseline (for example inflammatory papules/pustules or facial erythema). Typical durations of approval are provided for initial and continuation therapy.

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Initial Therapy Criteria

Authorization Criteria for Rosacea Topical Products

Authorization may be granted for the requested drug when the patient has a diagnosis of rosacea and the following criteria are met:

ALL of the following

Patient has a diagnosis of rosacea.
The patient has experienced a reduction in symptoms of rosacea from baseline (e.g., inflammatory papules or pustules, facial erythema).
Example symptom improvement required; no objective threshold provided.

Authorization Criteria for Rosacea Topical Products

Applicable Codes

Referenced products (brand and generic listed)mixedCovered

Emrosi	minocycline hydrochloride extended-release (indicated for inflammatory lesions of rosacea in adults)
Finacea Gel	azelaic acid 15% gel (topical treatment of inflammatory papules and pustules of mild to moderate rosacea)
Finacea Foam	azelaic acid 15% foam (topical treatment of inflammatory papules and pustules of mild to moderate rosacea)
Mirvaso	brimonidine topical gel 0.33% (for persistent nontransient erythema of rosacea in adults ≥18 years)
Noritate	metronidazole topical (treatment of inflammatory lesions and erythema of rosacea)
Rhofade	oxymetazoline hydrochloride cream 1% (for persistent facial erythema associated with rosacea in adults)
Soolantra	ivermectin cream (treatment of inflammatory lesions of rosacea)

Provider Actions

Prior Authorization

Authorization required for rosacea topical products

Authorization 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/pustules or facial erythema).

Documentation Required

Clinical evidence of symptom improvement

Provider should document baseline symptoms and subsequent reduction in symptoms (for example inflammatory papules/pustules or facial erythema) to support approval.

Background

Brand and generic topical (and one oral extended-release) products indicated for inflammatory lesions and/or erythema of rosacea include: Emrosi (minocycline HCl extended-release); Finacea gel and Finacea foam (azelaic acid 15%); Mirvaso (brimonidine topical gel 0.33%); Noritate (metronidazole topical); Rhofade (oxymetazoline cream 1%); and Soolantra (ivermectin cream). Note the specific limitations: Emrosi is indicated for inflammatory lesions and has not been evaluated for infections; Finacea products have not been evaluated for erythema in the absence of papules and pustules.