CurrentUnitedHealthcarePolicy 2025 P 2192-6

Tazorac® (tazarotene) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

UnitedHealthcare prior authorization and medical necessity criteria for coverage of topical Tazorac (tazarotene) 0.05% and 0.1% cream and gel for plaque psoriasis (and notes regarding acne indications). Defines initial authorization, reauthorization, approval durations, and additional clinical rules including use of automated approvals and possible supply limits.

Policy Summary

PayerUnitedHealthcare

PolicyTazorac® (tazarotene) - Prior Authorization/Medical Necessity - UnitedHealthcare Commercial Plans

Policy CodePolicy 2025 P 2192-6

Change TypeAnnual reviewreference updates

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must obtain prior authorization demonstrating diagnosis of plaque psoriasis AND history of failure, contraindication, or intolerance to a topical corticosteroid to obtain initial approval; authorization will be issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Effective Date updated to 6/1/2025 and annual review completed 3/2025 with updated references.

Initial authorization duration updated to 12 months (3/2024).

1Covered Indication (plaque psoriasis)

12 moInitial authorization duration

12 moReauthorization duration

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Coverage Summary

Coverage summary: UnitedHealthcare prior authorization and medical necessity criteria (Policy 2025 P 2192-6, status CURRENT, effective 6/1/2025) state that Tazarotene topical (Tazorac) 0.05% and 0.1% cream and gel is covered with criteria for the treatment of plaque psoriasis. Coverage is limited to plaque psoriasis; although the 0.1% formulations are indicated for acne, acne is not covered under this policy. The policy lists covered formulations/strengths as 0.05% and 0.1%. Initial authorization and reauthorization durations are 12 months.

Policy at-a-glance

Initial Therapy Criteria

Initial Authorization

Tazorac will be approved based on both of the following criteria:

Diagnosis of plaque psoriasis
History of failure, contraindication, or intolerance to a topical corticosteroid (e.g., clobetasol, halobetasol)

Continuation / Reauthorization Criteria

Reauthorization (Continuation Therapy)

Tazorac will be approved for reauthorization when the following criterion is met:

Documentation of positive clinical response to therapy
Positive clinical response: Documentation by provider indicating clinical improvement while on therapy (policy does not define numeric thresholds).

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required for initial coverage

Providers must obtain prior authorization demonstrating diagnosis of plaque psoriasis AND history of failure, contraindication, or intolerance to a topical corticosteroid to obtain initial approval; authorization will be issued for 12 months.

Prior Authorization

Reauthorization documentation requirement

For reauthorization, providers must document a positive clinical response to therapy; reauthorization will be issued for 12 months.

Documentation Required

Potential automated approval data sources

UnitedHealthcare may approve initial and reauthorization based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic via automated processes.

Applicable Codes

Example topical corticosteroids (for failure/contraindication/intolerance requirement)mixed

No codes listed

Clinical Evidence & References

Key evidence and sources cited in the policy include the Tazorac package insert (August 2019) and clinical guidelines and reviews spanning 2000–2024. Specifically referenced guidance includes AAD/NPF and other guideline/review publications (e.g., 2000 algorithm-based review, 2021 AAD-NPF topical psoriasis guidance, 2024 acne management guideline). The policy states it relies on these package labeling and guideline sources to inform the coverage criteria.

Background

Tazarotene topical formulations are indicated for plaque psoriasis (both 0.05% and 0.1% cream/gel) and the 0.1% cream/gel are also indicated for facial acne. For localized plaque psoriasis, topical corticosteroids and topical calcipotriene are recommended as initial therapy; tazarotene is described as an option to add for uncontrolled localized plaque psoriasis or when alternatives are inappropriate. Under this policy, use for acne is noted but coverage is restricted to plaque psoriasis. Initial authorization requires a diagnosis of plaque psoriasis and history of failure, contraindication, or intolerance to a topical corticosteroid; reauthorization requires documentation of a positive clinical response. Supply limits and automated approval based on claims/medication history or diagnosis codes may apply.

Definitions

Revision History

3/2024material_change

Material: Initial authorization duration updated to 12 months (change recorded in 3/2024).

3/2025non-material_updateLatest

Non-material: Effective Date updated to 6/1/2025 and annual review completed 3/2025 with updated references.