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ph-1178

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: The requested quantity (dose) does NOT exceed the program quantity limit OR The requested quantity (dose) is greater than the program quantity limit AND ONE of the following: BOTH of the following: The requested agent does not have a maximum FDA labeled dose for the requested indication AND Information has been provided to support therapy with a higher dose for the requested indication OR BOTH of the following: The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND 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 BOTH of the following: The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND Information has been provided to support therapy with a higher dose for the requested indication Length of Approval: up to 12 months

Module

Clinical Criteria for Approval

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

The requested quantity (dose) does NOT exceed the program quantity limit OR
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