CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Tazarotene 0.1% cream and gel — Coverage Criteria

Policy governs prior authorization and coverage criteria for tazarotene 0.1% cream and gel for members with plaque psoriasis or acne vulgaris, including age limits, required prior topical therapy trials, quantity limits, and authorization duration.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTazarotene 0.1% cream and gel — Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor/No material changes

Effective DateN/A

Next Review DateMay 1, 2025

Key ActionObtain prior authorization showing patient age/diagnosis and, for acne, documentation of trial and failure of two formulary topical acne therapies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauth duration

30 gper-fill limit

60 g30-day limit

≥12 / ≥18covered ages

Coverage Criteria

Initial approval criteria

Covered when ALL of the following are met:

Age and diagnosis: (A) Patient is 18 years or older AND diagnosis of plaque psoriasis; OR (B) Member is age 12 years or older AND diagnosis of acne vulgaris.

From policy criteria I.A and I.B

Prior therapy for acne vulgaris: If diagnosis is acne vulgaris, member has had an adequate trial and failure of two formulary acne vulgaris therapies (e.g., benzoyl peroxide gel; clindamycin/benzoyl peroxide gel; erythromycin gel or solution; tretinoin cream/gel).two failed topical therapies

From policy criterion I.C

Authorization duration: Authorization may be granted for 12 months.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTazarotene 0.1% cream and gel — Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor/No material changes

Effective DateN/A

Next Review DateMay 1, 2025

Key ActionObtain prior authorization showing patient age/diagnosis and, for acne, documentation of trial and failure of two formulary topical acne therapies.

SourceLink

On This Page

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Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for adults and eligible adolescents. Authorizations may be granted for up to 12 months when the member meets age and diagnosis criteria and required step-therapy trials have been documented in the medical record.

Authorization length: up to 12 months
Applies to: members >=18 with plaque psoriasis OR >=12 with acne vulgaris
Documentation: see Required documentation callout

Step Therapy

Step Therapy for Acne

For acne vulgaris, step therapy requires documented adequate trials and therapeutic failure of two formulary topical acne therapies before approval of non-formulary or advanced therapies.

Examples of acceptable topical trials: benzoyl peroxide gel; clindamycin/benzoyl peroxide gel; erythromycin gel or solution; tretinoin cream/gel
Both trials must be documented with dates, products tried, duration, and reason for failure/intolerance

Documentation Required

Required Documentation

The medical record must document age, diagnosis, prior therapies tried (including dates, dose/formulation, duration), and reason for failure or intolerance for each prior topical acne therapy trial.

Include start and stop dates for prior therapies
State clinical response or adverse effects leading to discontinuation

Denial Risk

Denial Triggers

Authorizations may be denied if age or diagnosis criteria are not met, or if the two required formulary topical acne therapy trials are not documented.

Missing documentation of two formulary topical acne trials
Inadequate trial duration or unclear reason for failure
Member does not meet age or diagnosis criteria

Definitions

inv-09: Adequate trial and failure — defines clinical evidence required for trials/intolerance

DefinitionClinical record evidence that two formulary topical acne therapies were used without sufficient therapeutic response or with intolerance; examples include benzoyl peroxide gel, clindamycin/benzoyl peroxide gel, erythromycin gel or solution, and tretinoin cream/gel.

Required number of trialsDocumentation of an adequate trial and failure of two formulary topical acne therapies is required when the diagnosis is acne vulgaris.

Examples of acceptable therapiesBenzoyl peroxide gel; clindamycin/benzoyl peroxide gel; erythromycin gel or solution; tretinoin cream or gel.

Purpose of documentationTo demonstrate lack of sufficient therapeutic response or intolerance to two topical formulary agents prior to authorization for tazarotene for acne vulgaris.

Applies toMembers with a diagnosis of acne vulgaris (age ≥12) seeking authorization for tazarotene 0.1%.

OpenPayer

Tazarotene 0.1% cream and gel — Coverage Criteria

Coverage Criteria

Provider Actions and Requirements

Definitions

Background