Asset Publisher
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:
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