CurrentUnitedHealthcarePolicy N/A

Topical alpha-adrenergic agents for rosacea (Mirvaso, Rhofade) - Prior Authorization-Notification

Prior authorization-notification policy for Mirvaso (brimonidine 0.33% topical gel) and Rhofade (oxymetazoline 1% topical cream) for treatment of persistent erythema of rosacea in adults; affects prescribers and pharmacy prior authorization processing for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyTopical alpha-adrenergic agents for rosacea (Mirvaso, Rhofade) - Prior Authorization-Notification

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization notification for Mirvaso or Rhofade; initial approvals require a diagnosis of rosacea and are issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Mirvaso; RhofadeDrugs covered

12 moAuthorization duration

AdultsIndicated population

Prior Auth-NotificationProgram type

Coverage Criteria

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Initial Authorization

Covered when ALL of the following are met:

Initial Authorization for Mirvaso or Rhofade: Diagnosis of rosacea

Authorization will be issued for 12 months

Reauthorization

Covered when ALL of the following are met:

Reauthorization for Mirvaso or Rhofade: Documentation of positive clinical response to therapy

Authorization will be issued for 12 months; state mandates and member-specific benefit plan coverage may impact reauthorization

The policy does not list any explicit medical exclusions. However, automated approval and re-approval processes may be used in some programs and therapeutic classes, and supply limits may be in place, which could affect initial approvals or reauthorization in practice. These operational limits are noted under the policy’s additional clinical rules and may constrain coverage even when clinical criteria are met.

Prior versions of the policy included medical necessity and step requirements that were subsequently removed. The current document does not enumerate conditions labeled as “not medically necessary”; the change history documents removal of prior medical necessity language and step requirements, and no new explicit noncoverage (not medically necessary) statements are present.

Coding and Authorization Details

Authorization duration

Authorization duration12 months

Applies toInitial authorizations and reauthorizations for Mirvaso or Rhofade

Reasoning noteAuthorization will be issued for 12 months when coverage criteria are met

Provider Actions and Requirements

Prior Authorization

Prior Authorization / Notification Required

Prior authorization/notification is required for Mirvaso (oxymetazoline cream) and Rhofade. Providers should submit prior authorization requests per UnitedHealthcare processes; approvals are typically issued for 12 months. Processing may include automated review of claims history and diagnosis codes, which can result in approval without additional documentation when criteria are met.

Affected products: Mirvaso (oxymetazoline cream), Rhofade
Authorization duration: 12 months

Step Therapy

Step Therapy Status

Step therapy and prior step requirements have been removed from the policy. There is no active step therapy specified for Mirvaso or Rhofade at this time. Providers should not expect prior-step documentation to be required, but must follow current prior authorization submission requirements.

No active step therapy for Mirvaso or Rhofade
Do not submit step-therapy documentation unless explicitly requested in an authorization decision

Documentation Required

Reauthorization Documentation Requirement

Reauthorization requests must include documentation demonstrating a positive clinical response to therapy (for example, clinical notes describing improvement in rosacea signs/symptoms). State mandates, federal regulatory requirements, and the member’s benefit plan may affect required documentation. When applicable, include prior authorization references and relevant ICD-10 diagnosis codes.

Required: clinical documentation of positive response to therapy
Include: relevant ICD-10 diagnosis codes and prior authorization identifiers
Note: state mandates and member-specific benefits may alter documentation needs

Note

Automated Approval Processes and Supply Limits

UnitedHealthcare may use automated approval and re-approval processes based on prior claim/medication history, diagnosis codes, and claim logic. These automated workflows can expedite decisions but may also enforce supply limits. Providers should verify any quantity or supply limits applied at the time of authorization and be prepared to supply supporting documentation if automated review does not sufficiently demonstrate medical necessity.

Automated approvals may rely on previous claims, medication history, and ICD-10 codes
Supply limits may be applied; verify limits during authorization
Providers may be asked for additional documentation if automated review is insufficient

Background

Mirvaso (brimonidine 0.33% topical gel) and Rhofade (oxymetazoline 1% topical cream) are topical alpha-adrenergic agonists indicated for the treatment of persistent (nontransient) facial erythema of rosacea in adults. These agents act via cutaneous vasoconstriction to reduce erythema and are applied topically; clinical response is monitored for continuation of therapy.

Definitions

Persistent (nontransient) erythema of rosacea

TermPersistent (nontransient) erythema of rosacea

DefinitionFacial redness associated with rosacea that is sustained rather than episodic

IndicationIndicated condition for topical alpha-adrenergic agonist therapy (Mirvaso, Rhofade) in adults

Initial Therapy Criteria

Initial Authorization

Covered when ALL of the following are met:

Initial Authorization for Mirvaso or Rhofade: Diagnosis of rosacea

Authorization will be issued for 12 months

Continuation / Reauthorization Criteria

Reauthorization

Covered when ALL of the following are met:

Reauthorization for Mirvaso or Rhofade: Documentation of positive clinical response to therapy

Authorization will be issued for 12 months; state mandates and member-specific benefit plan coverage may impact reauthorization

Step Therapy

Step	Requirement / Status	Notes
1	No active step therapy requirement specified	Policy history: prior step and medical necessity language was removed (7/2024); current document indicates no active step therapy.

Quantity Limits

Mirvaso or Rhofade

Quantity limitsSupply limits may be in place (unspecified)

ImpactSupply limits may affect approvals or dispensing despite coverage criteria

Program noteUse of automated approval and re-approval processes varies by program and/or therapeutic class

Policy Summary

PayerUnitedHealthcare

PolicyTopical alpha-adrenergic agents for rosacea (Mirvaso, Rhofade) - Prior Authorization-Notification

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization notification for Mirvaso or Rhofade; initial approvals require a diagnosis of rosacea and are issued for 12 months.

SourceLink

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