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Topical Psoriasis Quantity Limit

Policy Number: PH-1178

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.

POLICY REVIEW CYCLE

Effective Date

Date of Origin 

1/1/2024

7/1/2018

FDA APPROVED INDICATIONS AND DOSAGE

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Calcipotriene Soln 0.005% (50 MCG/ML)

0.005 %

120

mLs

30

DAYS

Calcitrene

Calcipotriene Oint 0.005%

0.005 %

120

Grams

30

DAYS

Clobex

Clobetasol Propionate Lotion 0.05%

0.05 %

118

mLs

30

DAYS

Clobex

Clobetasol Propionate Spray 0.05%

0.05 %

125

mLs

30

DAYS

Clobex ; Clodan

Clobetasol Propionate Shampoo 0.05%

0.05 %

118

mLs

30

DAYS

Dovonex

Calcipotriene Cream 0.005%

0.005 %

120

Grams

30

DAYS

Duobrii

halobetasol propionate-tazarotene lotion

0.01-0.045 %

200

Grams

30

DAYS

Enstilar

Calcipotriene-Betamethasone Dipropionate Foam 0.005-0.064%

0.005-0.064 %

120

Grams

30

DAYS

Olux

Clobetasol Propionate Foam 0.05%

0.05 %

100

Grams

30

DAYS

Olux-e ; Tovet

Clobetasol Propionate Emulsion Foam 0.05%

0.05 %

100

Grams

30

DAYS

Sernivo

Betamethasone Dipropionate Spray Emulsion 0.05% (Base Equiv)

0.05 %

120

mLs

30

DAYS

Sorilux

Calcipotriene Foam 0.005%

0.005 %

120

Grams

30

DAYS

Taclonex

Calcipotriene-Betamethasone Dipropionate Oint 0.005-0.064%

0.005-0.064 %

120

Grams

30

DAYS

Taclonex

Calcipotriene-Betamethasone Dipropionate Susp 0.005-0.064%

0.005-0.064 %

120

Grams

30

DAYS

Vectical

Calcitriol Oint 3 MCG/GM

3 MCG/GM

200

Grams

30

DAYS

Wynzora

Calcipotriene-Betamethasone Dipropionate Cream

0.005-0.064 %

120

Grams

30

DAYS

Zoryve

Roflumilast Cream

0.3 %

60

Grams

30

DAYS

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Calcipotriene Soln 0.005% (50 MCG/ML)

0.005 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Calcitrene

Calcipotriene Oint 0.005%

0.005 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Clobex

Clobetasol Propionate Lotion 0.05%

0.05 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Clobex

Clobetasol Propionate Spray 0.05%

0.05 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Clobex ; Clodan

Clobetasol Propionate Shampoo 0.05%

0.05 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Dovonex

Calcipotriene Cream 0.005%

0.005 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Duobrii

halobetasol propionate-tazarotene lotion

0.01-0.045 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Enstilar

Calcipotriene-Betamethasone Dipropionate Foam 0.005-0.064%

0.005-0.064 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Olux

Clobetasol Propionate Foam 0.05%

0.05 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Olux-e ; Tovet

Clobetasol Propionate Emulsion Foam 0.05%

0.05 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sernivo

Betamethasone Dipropionate Spray Emulsion 0.05% (Base Equiv)

0.05 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Sorilux

Calcipotriene Foam 0.005%

0.005 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Taclonex

Calcipotriene-Betamethasone Dipropionate Oint 0.005-0.064%

0.005-0.064 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Taclonex

Calcipotriene-Betamethasone Dipropionate Susp 0.005-0.064%

0.005-0.064 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vectical

Calcitriol Oint 3 MCG/GM

3 MCG/GM

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Wynzora

Calcipotriene-Betamethasone Dipropionate Cream

0.005-0.064 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zoryve

Roflumilast Cream

0.3 %

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) is greater than the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does not have a maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit OR
    3. BOTH of the following:
      1. The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication

Length of Approval: up to 12 months

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

BCBSAL _  Commercial _ CS _ Topical Psoriasis _QL _ProgSum_ 1/1/2024