CurrentNeighborhood Health Plan of Rhode IslandPolicy Tazorac PA Policy 353-A, 224-A UDR 07-2024

Tazarotene (Tazorac) topical prior authorization

Criteria governing prior authorization for topical tazarotene (Tazorac cream and gel) for acne vulgaris and plaque psoriasis for members of Neighborhood Health Plan of Rhode Island as implemented via CVS Caremark criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTazarotene (Tazorac) topical prior authorization

Policy CodePolicy Tazorac PA Policy 353-A, 224-A UDR 07-2024

Change TypeMinor / No material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization with documentation of indication, BSA for psoriasis, and prior topical corticosteroid trial or intolerance when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2FDA‑approved indications covered (acne, plaque psoriasis)

20%Maximum BSA for gel psoriasis use specified

4 moInitial authorization duration for acne (224-A)

3 moInitial authorization duration for plaque psoriasis

12–36 mo

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Coverage Criteria for Tazorac (tazarotene) Topical

Plaque Psoriasis — Initial

Covered when ALL of the following are met

Plaque psoriasis approval: The plaque psoriasis affects less than or equal to 20% of the patient's body surface area (BSA)BSA <= 20%

Applies to Tazorac cream or gel per FDA indications

Topical corticosteroid requirement (ONE of): Patient meets ONE of the following: inadequate response to at least ONE topical corticosteroid; OR intolerance to at least ONE topical corticosteroid; OR contraindication to all topical corticosteroids

Acne Vulgaris — Initial/Continuation

Covered when the following are met

Acne vulgaris approval: Requested for topical treatment of acne vulgaris

Clinical response (initial or continuation): For continuation requests: the patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions); for initial requests: indication must align with FDA‑approved acne formulation/strength (e.g., Tazorac cream 0.1%)clinical improvement

The safety of topical tazarotene (Tazorac) use on more than 20% body surface area (BSA) has not been established for either plaque psoriasis or acne vulgaris. Requests that would result in treatment of >20% BSA may be denied due to insufficient safety data; prior authorization criteria and approvals are limited to uses within this BSA threshold where specified.

Coding and Body Surface Area Guidance

Body surface area for gel psoriasis — <= 20% BSA

BSA threshold for gel (value)<= 20% body surface area for plaque psoriasis when using Tazorac gel (0.05% and 0.1%).

Applicable formulationTazorac gel, 0.05% and 0.1% (plaque psoriasis).

Clinical implicationRequests for gel use should document percent BSA involved; approvals limited when BSA is 20% or less.

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior authorization required for Tazorac (plaque psoriasis or acne)

Prior authorization is required. Authorization may be granted when the requested drug is being prescribed for the treatment of plaque psoriasis or acne vulgaris and the applicable FDA‑aligned coverage criteria and supporting documentation are submitted; initial and continuation durations differ by policy variant (see durations).

Step Therapy

Topical corticosteroid step requirement for plaque psoriasis

For plaque psoriasis, the patient must meet one of the topical corticosteroid-related criteria before authorization: inadequate response to at least one topical corticosteroid, intolerance to at least one topical corticosteroid, or a contraindication to all topical corticosteroids.

Inadequate response to ≥1 topical corticosteroid
Intolerance to ≥1 topical corticosteroid
Contraindication to all topical corticosteroids

Background on Tazarotene (Tazorac)

Tazarotene (Tazorac) is a topical retinoid available in cream and gel formulations. Gel formulations (0.05% and 0.1%) are indicated for treatment of plaque psoriasis up to 20% body surface area, while cream 0.1% is indicated for topical treatment of acne vulgaris. Prior authorization is required and will follow indication‑specific criteria (see coverage criteria); safety and efficacy beyond the labeled BSA for gel have not been established.

Definitions and Limits

Body Surface Area (BSA) limit — Tazorac gel

Policy limitIndication for Tazorac gel in plaque psoriasis is limited to involvement of up to 20% body surface area.

Safety beyond limitSafety of Tazorac gel use on more than 20% body surface area has not been established (psoriasis or acne).

Documentation neededProviders should document BSA when requesting Tazorac gel for plaque psoriasis to demonstrate eligibility under the 20% limit.