CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Prior authorization criteria for topical tazarotene (Tazorac) for plaque psoriasis and acne vulgaris

Prior authorization criteria for topical tazarotene (Tazorac) formulations for plaque psoriasis and acne vulgaris, governing coverage decisions for members of Neighborhood Health Plan of Rhode Island via the CVS Caremark criteria set.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior authorization criteria for topical tazarotene (Tazorac) for plaque psoriasis and acne vulgaris

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of body surface area (≤20% for plaque psoriasis gel) and evidence of prior topical corticosteroid trial or positive clinical response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

<=20%psoriasis BSA limit

4 moinitial approval (acne)

12 mocontinuation approval (acne)

3 moinitial approval (psoriasis)

Coverage Criteria

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Plaque Psoriasis — Initial coverage criteria

Covered when ALL of the following are met for plaque psoriasis (gel/cream):

Plaque psoriasis coverage: Plaque psoriasis affects less than or equal to 20% body surface area (BSA)<=20% BSA

Gel safety >20% BSA not established

Prior corticosteroid requirement: The patient meets ONE of: inadequate response to at least one topical corticosteroid; contraindication to all topical corticosteroids; intolerance to at least one topical corticosteroid

The patient may continue to use a topical corticosteroid concomitantly

Clinical response alternative: The patient has achieved or maintained a positive clinical response (e.g., clear or almost clear outcome, patient satisfaction)

Authorization may be granted when criteria below are met

Acne Vulgaris — Coverage criteria

Covered when the following is met for acne vulgaris:

Acne vulgaris coverage: The patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions)

Indication applies to topical formulations (e.g., Tazorac cream 0.1% and gel 0.1% for facial acne)

Use of Tazorac gel on more than 20% body surface area (BSA) is not established and therefore excluded from standard approval. Requests or indications that would require application to >20% BSA should be routed for denial or exceptional review per payer policy because safety has not been established.

The efficacy of Tazorac gel for acne that has previously been treated with other topical retinoids or that is resistant to oral antibiotics has not been established. When reviewing requests for acne, confirm the formulation and prior treatment history; use of gel in these prior-treatment scenarios is considered unsupported by the evidence and may be denied.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Tazorac gel when used for plaque psoriasis or acne vulgaris. Authorization for plaque psoriasis is limited to cases where the affected body surface area (BSA) is ≤ 20% and the requester supplies required clinical documentation (see below). The safety of Tazorac gel on > 20% BSA has not been established.

Authorization limited to plaque psoriasis with BSA ≤ 20%
Authorization requires submission of clinical documentation (see documentation callout)

Step Therapy

Topical Corticosteroid Step

Authorization for topical Tazorac for plaque psoriasis may be granted only when the patient meets clinical step requirements for topical corticosteroids: the patient has had inadequate response to at least one topical corticosteroid, or has a contraindication to all topical corticosteroids, or has experienced intolerance to at least one topical corticosteroid. Continued concomitant use of a corticosteroid product is permitted.

Examples of topical corticosteroids: clobetasol, fluocinonide, mometasone, triamcinolone

Documentation Required

Required Clinical Documentation

Submit documentation demonstrating BSA involvement and clinical response. For plaque psoriasis provide current BSA estimate showing ≤ 20% involvement. For acne vulgaris or plaque psoriasis, provide objective evidence of positive clinical response (for acne: reduction in lesion count; for psoriasis: clear or almost clear outcome, patient satisfaction, or other clinician-assessed improvement). Include prior treatment history documenting trials of topical corticosteroids (dates, agents, and outcome) or documentation of contraindication/intolerance if applicable.

BSA documentation showing ≤ 20% for plaque psoriasis
Clinical measures of improvement (lesion counts, clinician assessment, patient-reported outcomes)
Prior treatment history with topical corticosteroids (agent, duration, response) or documentation of contraindication/intolerance

Denial Risk

BSA and Safety Limits / Denial Risk

Do not approve requests when BSA > 20% due to unestablished safety. Deny if required documentation (BSA, clinical response, or prior topical corticosteroid history/contraindication) is not provided.

Requests lacking BSA estimate or evidence of clinical response are subject to denial
Requests without documentation of prior topical corticosteroid trial or valid contraindication/intolerance are subject to denial