Asset Publisher

ph-1178

print Print

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.

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 Agent GPI

Target Agent Name(s)

Strength

QL Amount

Dose Form

Days Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

90250025003710

CALCIPOTRIENE*Calcipotriene Cream 0.005%

0.005 %

120.0

GRAMS

30

Days

90250025003920

CALCIPOTRIENE*Calcipotriene Foam 0.005%

0.005 %

120.0

GRAMS

30

Days

90250025004210

CALCIPOTRIENE*Calcipotriene Oint 0.005%

0.005 %

120.0

GRAMS

30

Days

90250025002020

CALCIPOTRIENE*Calcipotriene Soln 0.005% (50 MCG/ML)

0.005 %

120.0

MLS

30

Days

90559902324225

CALCIPOTRIENE/BETAMETHASO*Calcipotriene-Betamethasone Dipropionate Oint 0.005-0.064%

0.005 %

120.0

GRAMS

30

Days

90559902321825

CALCIPOTRIENE/BETAMETHASO*Calcipotriene-Betamethasone Dipropionate Susp 0.005-0.064%

0.005 %

120.0

GRAMS

30

Days

90250028004220

CALCITRIOL*Calcitriol Oint 3 MCG/GM

3 MCG/GM

200.0

GRAMS

30

Days

90550025203920

CLOBETASOL PROPIONATE*Clobetasol Propionate Emulsion Foam 0.05%

0.05 %

100.0

GRAMS

30

Days

90550025103920

CLOBETASOL PROPIONATE*Clobetasol Propionate Foam 0.05%

0.05 %

100.0

GRAMS

30

Days

90550025104110

CLOBETASOL PROPIONATE*Clobetasol Propionate Lotion 0.05%

0.05 %

118.0

MLS

30

Days

90550025104520

CLOBETASOL PROPIONATE*Clobetasol Propionate Shampoo 0.05%

0.05 %

118.0

MLS

30

Days

90550025100910

CLOBETASOL PROPIONATE*Clobetasol Propionate Spray 0.05%

0.05 %

125.0

MLS

30

Days

905599024841

DUOBRII*halobetasol propionate-tazarotene lotion

0.01 %

200.0

GRAMS

30

Days

90559902323930

ENSTILAR*Calcipotriene-Betamethasone Dipropionate Foam 0.005-0.064%

0.005 %

120.0

GRAMS

30

Days

90550020001620

SERNIVO*Betamethasone Dipropionate Spray Emulsion 0.05% (Base Equiv)

0.05 %

120.0

MLS

30

Days

90559902323720

WYNZORA*Calcipotriene-Betamethasone Dipropionate Cream 0.005-0.064%

0.005 %

120.0

GRAMS

30

Days

90250045003720

ZORYVE*Roflumilast Cream 0.3%

0.3 %

60.0

GRAMS

30

Days

CLIENT SUMMARY – QUANTITY LIMITS

Agent Names

Strength

Client Formulary

CALCIPOTRIENE*Calcipotriene Cream 0.005%

0.005 %

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

CALCIPOTRIENE*Calcipotriene Foam 0.005%

0.005 %

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

CALCIPOTRIENE*Calcipotriene Oint 0.005%

0.005 %

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

CALCIPOTRIENE*Calcipotriene Soln 0.005% (50 MCG/ML)

0.005 %

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

CALCIPOTRIENE/BETAMETHASO*Calcipotriene-Betamethasone Dipropionate Oint 0.005-0.064%

0.005 %

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

CALCIPOTRIENE/BETAMETHASO*Calcipotriene-Betamethasone Dipropionate Susp 0.005-0.064%

0.005 %

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

CALCITRIOL*Calcitriol Oint 3 MCG/GM

3 MCG/GM

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

CLOBETASOL PROPIONATE*Clobetasol Propionate Emulsion Foam 0.05%

0.05 %

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

CLOBETASOL PROPIONATE*Clobetasol Propionate Foam 0.05%

0.05 %

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

CLOBETASOL PROPIONATE*Clobetasol Propionate Lotion 0.05%

0.05 %

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

CLOBETASOL PROPIONATE*Clobetasol Propionate Shampoo 0.05%

0.05 %

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

CLOBETASOL PROPIONATE*Clobetasol Propionate Spray 0.05%

0.05 %

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

DUOBRII*halobetasol propionate-tazarotene lotion

0.01 %

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

ENSTILAR*Calcipotriene-Betamethasone Dipropionate Foam 0.005-0.064%

0.005 %

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

SERNIVO*Betamethasone Dipropionate Spray Emulsion 0.05% (Base Equiv)

0.05 %

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

WYNZORA*Calcipotriene-Betamethasone Dipropionate Cream 0.005-0.064%

0.005 %

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

ZORYVE*Roflumilast Cream 0.3%

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

QUANTITY LIMIT CLINICAL CRITERIA OPERATIONAL LEVEL OF EVIDENCE REQUIREMENTS

Module

Ops Set Up

Validation Options

Other Explanation

Validation:  Apply Baseline and go to Validation Options

 

DOCUMENT HISTORY                                                                                                                                                                           

Approval Date MM/YYYY

Approved By

Notes

-

Original Client Specific Review Client Specific criteria, approved by BCBS AL 04/2018

Original Implementation 7/1/2018

Administrative Action (addition of Duobrii) 05/2019

Client Specific Annual Review Client Specific criteria, maintained, reviewed by BCBS AL 08/2019

Administrative Action (note branded generic of Sorilux, Taclonex) 01/2020

Client Specific Mid-Year Review Client Specific criteria, with changes to question set, approved by BCBS AL 03/2020

Client Specific Annual Review, Prime Standard criteria, no changes, approved by BCBS AL 07/2020

Client Specific Mid-Year Review Client Specific criteria, with changes, approved by BCBS AL 10/2020

Client Specific Annual Review Client Specific criteria, with changes, approved by BCBS AL 10/2021

Administrative Action (addition of Vtama) 05/2022

Administrative Action (addition of Zoryve) 08/2022

Client Specific Mid-Year Review Client Specific criteria, with changes (removal of Vtama), approved by BCBS AL 09/2022

10-2022

BCBS AL

Client Specific Annual Review Client Specific criteria, criteria maintained, approved by BCBS AL 10/2022

POLICY REVIEW CYCLE                                                                                                                                                                           

Effective Date

Date of Origin 

Status

1/1/2023

Draft

 

 

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.

 

 

Commercial _ CS _ Topical Psoriasis Quantity Limit _ 1/1/2023