CurrentNeighborhood Health Plan of Rhode IslandPolicy Tazorac PA Policy 353-A,224-A UDR 04-2023 (1)

Prior authorization criteria for topical tazarotene (Tazorac)

Prior authorization criteria for topical tazarotene (Tazorac) products for plaque psoriasis and acne vulgaris for members of Neighborhood Health Plan of Rhode Island as implemented via CVS Caremark.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPrior authorization criteria for topical tazarotene (Tazorac)

Policy CodePolicy Tazorac PA Policy 353-A,224-A UDR 04-2023 (1)

Change TypeNo material change

Effective DateApr 1, 2023

Next Review Date

Key ActionObtain prior authorization and document diagnosis, psoriasis BSA ≤20% (if psoriasis), and trial of ≥1 topical corticosteroid or intolerance/contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤20%BSA limit for psoriasis

Cream & GelFormulations noted

≥1 topical steroidRequired prior trial

Coverage Criteria

Initial and continuation coverage criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Diagnosis and indication: Patient has a diagnosis of plaque psoriasis or acne vulgaris and the requested tazarotene formulation is prescribed for that indicated condition

See policy indications and coverage statement (chunks 6-7).

Psoriasis body surface area: If the request is for plaque psoriasis, the affected body surface area must be less than or equal to 20%<=20% BSA

Safety of gel use on >20% BSA not established (chunks 8,5).

Prior therapy or exception: Either the patient has experienced an inadequate treatment response to at least one topical corticosteroid OR the patient has experienced an intolerance to at least one topical corticosteroid OR the patient has a contraindication that would prohibit a trial of topical corticosteroidsat least 1 topical corticosteroid trial unless intolerance/contraindication

Step-therapy expectation and allowed exceptions per policy (chunks 10,9).

Continuation of therapy: For continuation requests, the patient must have achieved or maintained a positive clinical response with documented improvement

Continuation requirement documented in policy (chunk 10).

Provider Actions and Authorization Requirements

Prior Authorization

Prior authorization coverage requirements

Prior authorization is required for coverage of Tazorac (tazarotene) gel. Submit clinical documentation supporting the diagnosis and that coverage criteria are met before dispensing.

Applies to requests for Tazorac Gel (tazarotene).
Ensure prior authorization is obtained for both new and continuation requests when required by policy.

Step Therapy

Step therapy — topical corticosteroid first

Step therapy requires that patients with plaque psoriasis or acne have tried a topical corticosteroid prior to approval of Tazorac unless there is documented intolerance or contraindication.

At least one topical corticosteroid trial is required for plaque psoriasis unless intolerance or contraindication is documented.
For acne vulgaris, follow standard acne treatment guidelines; topical corticosteroid trial requirement applies when clinically relevant.

Documentation Required

Clinical response and prior therapy documentation

Document the clinical response and prior therapies in the prior authorization submission. For continuation requests, provide evidence of maintained or improved clinical response.

Provide diagnosis (plaque psoriasis or acne vulgaris) and percent body surface area (BSA) affected for psoriasis.
For initial requests, document trial and inadequate response to at least one topical corticosteroid, or documented intolerance/contraindication to topical corticosteroids.
For continuation requests, document that the patient has achieved or maintained a positive clinical response (e.g., improvement in signs/symptoms) while on therapy.

Denial Risk

BSA limit (denial risk when >20% BSA)

Requests for treatment of plaque psoriasis affecting more than 20% body surface area are at risk for denial because safety on >20% BSA has not been established.

Document BSA; requests where psoriasis involves >20% BSA may be denied.
Consider alternative systemic therapies for extensive disease.

Denial Risk

Coverage criteria not met — requests at risk for denial

Coverage criteria not met when required documentation or prior therapy trials are missing; such requests are at risk for denial.

Missing documentation of diagnosis, BSA, prior topical corticosteroid trial (or intolerance/contraindication), or clinical response for continuation requests may result in denial.
Ensure all required prior therapy and response information is included with the prior authorization.

Background

Tazarotene (Tazorac) is a topical retinoid available as cream and gel formulations and is indicated for the topical treatment of plaque psoriasis and for facial acne vulgaris in specific strengths and formulations. Gel formulations have established safety for psoriasis (and acne) only when applied to ≤ 20% BSA; use on greater surface area has not been shown to be safe.

Indications / Definitions

Indications — formulations and labeled indications

Cream formulations and indicationsTazorac cream 0.05% and 0.1%: indicated for topical treatment of plaque psoriasis

Gel formulations and psoriasis indicationTazorac gel 0.05% and 0.1%: indicated for topical treatment of plaque psoriasis up to 20% BSA

Gel formulation and acne indicationTazorac gel 0.1%: indicated for topical treatment of facial mild to moderate acne vulgaris

Limitations of useSafety of Tazorac gel use on >20% body surface area has not been established for psoriasis or acne