Retinoids & Topical Psoriasis Agents – Enhanced/Essential

Restricted Product(s)

Restriction applies to brand and generic products

• Aklief (trifarotene)
• Arazlo lotion (tazarotene 0.045%) 
• Duobrii lotion (halobetasol 0.01% / tazarotene 0.045%)
• Fabior (tazarotene) 
• Sorilux (calcipotriene 0.005% foam) 
• Tazarotene 0.1% foam
• Tazorac gel and cream (tazarotene) 
• Vtama cream (tapinarof 1%)

FDA Approved Use

• Aklief, Arazlo, Fabior, Tazarotene 0.1% foam
  • For the topical treatment of acne vulgaris.
• Duobrii, Sorilux
  • For the topical treatment of plaque psoriasis.
• Tazorac
  • For the topical treatment of acne vulgaris.
  • For the topical treatment of plaque psoriasis.
• Vtama
  • For the topical treatment of plaque psoriasis.
  • For the topical treatment of atopic dermatitis.

Criteria for Approval of Restricted Product(s)

1. The request is for Duobrii lotion; AND
   1. The patient has a diagnosis of plaque psoriasis; AND 
   2. The patient has tried and failed or has a clinical intolerance/contraindication to generic tazarotene; AND 
   3. The duration of treatment will be or is no longer than 8 weeks; OR 
2. The request is for Tazorac or generic tazarotene; AND
   1. The patient has a diagnosis of plaque psoriasis; OR 
   2. The patient has a diagnosis of mild to moderate acne vulgaris; AND
      1. The patient has tried and failed or has a clinical intolerance/contraindication to generic tretinoin; OR 
3. The request is for Aklief, Arazlo, Fabior, or Tazarotene 0.1% foam; AND
   1. The patient has a diagnosis of mild to moderate acne vulgaris; AND 
   2. The patient has tried and failed or has a clinical intolerance/contraindication to generic tretinoin; AND 
4. The request is for Sorilux or Calcipotriene 0.005% foam (authorized generic Sorilux); AND 
   1. The patient has a diagnosis of plaque psoriasis; AND 
   2. The patient has tried and failed or has a clinical intolerance/contraindication to generic calcipotriene; OR 
5. The request is for Vtama; AND 
   1. The patient has a diagnosis of plaque psoriasis; AND
      1. The patient has tried and failed ONE of the following: generic calcipotriene, generic topical corticosteroid, generic tazarotene; OR
      2. The patient has a clinical intolerance/contraindication to ALL of the alternatives that have not been tried; OR
   2. The patient has a diagnosis of atopic dermatitis; AND
      1. The patient has tried and failed ONE of the following: a generic topical corticosteroid or a topical calcineurin inhibitor; OR
      2. The patient has a clinical intolerance/contraindication to ALL of the alternatives that have not been tried; OR
6. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

Duration of Approval: 365 days (1 year)

References

All information referenced is from FDA package insert unless otherwise noted below.

Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB,et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009 Apr;60(4):643-59.

Policy Implementation/Update Information

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.

Jan 2025: Criteria change (Vtama): Added criteria for Vtama expanded indication to cover atopic dermatitis. 

Jan 2024: Criteria update: Removed Zoryve cream from policy.

Oct 2022: Criteria update: Formatting changes.

Aug 2022: Criteria change: Added Zoryve to policy.

May 2022: Criteria change: Added Vtama 1% cream to policy and changed duration of approval to 365 days (1 year).

April 2021: Criteria update: Added Tazarotene 0.1% foam to the policy.

April 2021: Criteria update: Annual criteria review. Addition of Sorilux to policy.
Historical policy changes prior to 2021 can be obtained from BCBSNC Corporate Pharmacy