Acne-Rosacea Effective August 1, 2019 - PDF Document

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  1. Acne-Rosacea Effective August 1, 2019 ☒ MassHealth ☒Commercial/Exchange ☒ Pharmacy Benefit ☐ Medical Benefit (NLX) Plan ☐ Prior Authorization ☐ Quantity Limit ☒ Step Therapy Program Type Benefit Specialty Limitations N/A Specialty Medications Phone: 866-814-5506 Non-Specialty Medications Phone: 877-433-7643 Phone: 800-294-5979 Phone: 855-582-2022 Medical Specialty Medications (NLX) Phone: 844-345-2803 All Plans Fax: 866-249-6155 Contact Information MassHealth Commercial Exchange Fax: 866-255-7569 Fax: 888-836-0730 Fax: 855-245-2134 All Plans Fax: 844-851-0882 Exceptions N/A Overview Prescriptions that meet the initial step therapy requirements will adjudicate automatically at the point of sale. If the prescription does not meet the initial step therapy requirements, the prescription will deny with a message indicating that prior authorization (PA) is required. Refer to the criteria below and submit a PA request for the members who do not meet the initial step therapy requirements at the point of sale. Initial Step-Therapy Requirements: First-Line: Medications listed on first-line are covered without prior-authorization. Second-Line: Second-line medications will pay if the member has filled at least two different first-line medications or a second-line medication within the past 180 days. Coverage Guidelines FIRST-LINE Medications for Acne Vulgaris Generic benzoyl peroxide (various formulations) Generic clindamycin 1% Generic erythromycin 2% Generic sulfacetamide 10% & sulfur 5% Generic sulfacetamide 10% **Topical Retinoids: Generic tretinoin cream (0.05% & 0.1%) Generic tretinoin gel (0.01%, 0.025% & 0.1%) SECOND-LINE Topical Anti-infectives: OTC benzoyl peroxide Topical Anti-infectives: Azelex (azelaic acid) 20% cream Aczone (dapsone) 7.5% gel Dapsone 5% gel Topical Retinoids: Atralin (tretinoin) 0.05% gel adapalene 0.3% gel (RX) adapalene 0.1% cream (RX) Differin (adapalene) 0.1% lotion Tazarotene 0.1% cream Tazorac (tazarotene) 0.05% cream 399 Revolution Drive, Suite 810, Somerville, MA 02145 | allwayshealthpartners.org AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company

  2. FIRST-LINE SECOND-LINE Differin OTC (adapalene) 0.1% Gel Tazorac (tazarotene) 0.05% & 0.1% gel tretinoin microsphere 0.04%, 0.1% gel Fabior (tazarotene) 0.1% aerosol foam Medications for Acne Rosacea Generic metronidazole 0.75% cream, gel, lotion metronidazole 1% gel Noritate (metronidazole) 1% cream azelaic acid 15% gel Ivermectin (Soolantra) 1% cream If a member does not meet the initial step therapy requirements, then approval of a second-line medication will be granted if the member meets the following criteria: Azelex cream & Aczone 7.5% gel & dapsone 5% gel 1.Patient must have a diagnosis of acne vulgaris (comedonal acne, cystic acne, etc.) or rosacea AND 2.Patient has had a documented inadequate response, side effect, or allergy to at least two (2) different generic topical anti-infective agents used separately or together (i.e., clindamycin, erythromycin, benzoyl peroxide, sulfacetamide, or sodium sulfacetamide/sulfur) Atralin, adapalene 0.3% gel, adapalene 0.1% cream, Differin 0.1% lotion, tretinoin microsphere 0.04%, 0.1% gel 1.Patient must have a diagnosis of ichthyosis, hyperkeratosis, acne vulgaris (comedonal acne, cystic acne, etc.), or rosacea AND 2.Patient has had a documented inadequate response, side effect, or allergy to a preferred generic tretinoin cream or gel OR Differin OTC 0.1% gel. Tazorac cream/gel 0.05%, tazarotene 0.1% cream & Fabior foam 1.Patient must have a diagnosis of plaque psoriasis OR 1.Patient must have a diagnosis of acne vulgaris (comedonal acne, cystic acne, etc.), or rosacea AND 2.Patient has had a documented inadequate response, side effect, or allergy to a preferred generic tretinoin cream or gel OR Differin OTC 0.1% gel. Azelaic acid 15% Gel, metronidazole 1% and ivermectin 1% 1.Patient must have a diagnosis of rosacea AND 2.Patient has had a documented inadequate response, side effect, or allergy to generic metronidazole 0.75% gel, lotion, or cream Limitations 1.Approvals will be granted for 12 months. 2.All prescriptions for topical Retinoids will require PA for members 26 years of age and older. References 1.Benzoyl peroxide) [prescribing information]. Scottsdale, AZ: ProGen Inc.; received February 2017. 2.Erygel (erythromycin) [prescribing information]. Newtown, PA: Prestium Pharma; August 2015 399 Revolution Drive, Suite 810, Somerville, MA 02145 | allwayshealthpartners.org AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company

  3. 3.Plexion (sodium sulfacetamide/sulfur) cleanser [prescribing information]. Houston, TX: Brava Pharmaceuticals LLC; January 2014 4.Ovace Plus (sulfacetamide) foam [prescribing information]. San Antonio, TX: Mission Pharmacal Co; January 2015. 5.Altreno (tretinoin) [prescribing information]. Bridgewater, NJ: Valeant Pharmaceuticals North America LLC; August 2018. 6.Differin Gel 0.1% (adapalene) [prescribing information]. Fort Worth, TX: Galderma; June 2018. 7.Azelex (azelaic acid) [prescribing information]. Irvine, CA: Allergan; September 2015. 8.Aczone 5% Gel (dapsone) [prescribing information]. Irvine, CA: Allergan; May 2018.: 9.Avita (tretinoin) gel [prescribing information]. Morgantown, WV: Mylan Pharmaceuticals; January 2018. 10.Differin Gel 0.3% (adapalene) [prescribing information]. Fort Worth, TX: Galderma; December 2013. 11.Differin Lotion (adapalene) [prescribing information]. Fort Worth, TX: Galderma; April 2013. 12.Tazorac cream (tazarotene) [prescribing information]. Irvine, CA: Allergan, Inc; July 2017 13.Tazorac gel (tazarotene) [prescribing information]. Irvine, CA: Allergan, Inc; April 2018. 14.Flagyl Cream (metronidazole) [product monograph]. Laval, Quebec, Canada: Sanofi-Aventis Canada Inc; August 2018. 15.MetroLotion (metronidazole) [prescribing information]. Fort Worth, TX: Galderma Laboratories; February 2017. 16.Metronidazole gel [prescribing information]. Bridgewater, NJ: Valeant; March 2014 17.Noritate (metronidazole) 1% cream [prescribing information]. Bridgewater, NJ: Valeant; March 2018. 18.Finacea (azelaic acid) gel [prescribing information]. Whippany, NJ: Bayer HealthCare Pharmaceuticals; August 2018 19.Ivermectin (Soolantra) (ivermectin) [prescribing information]. Fort Worth, TX: Galderma Laboratories, L.P.; April 2018. 20.Wolf JE Jr, Kerrouche N, Arsonnaud S. Efficacy and safety of once-daily metronidazole 1% gel compared with twice-daily azelaic acid 15% gel in the treatment of rosacea. Cutis 2006; 77:3. 21.Conde JF, Yelverton CB, Balkrishnan R, et al. Managing rosacea: a review of the use of metronidazole alone and in combination with oral antibiotics. J Drugs Dermatol 2007; 6:495. 22.Webster GF, Berson D, Stein LF, et al. Efficacy and tolerability of once-daily tazarotene 0.1% gel versus once-daily tretinoin 0.025% gel in the treatment of facial acne vulgaris: a randomized trial. Cutis 2001; 67:4. Review History 03/21/05 – Reviewed 02/27/06 – Updated 03/05/07 – Updated 12/20/07 – Updated 010/3/08 – Updated 02/25/08 – Updated 02/23/09 – Updated 09/02/09 – Avita note 02/22/10 – Updated 06/18/10 – Adapalene gel 07/23/10 – Adapalene cr 08/02/10 – Tretin-x 399 Revolution Drive, Suite 810, Somerville, MA 02145 | allwayshealthpartners.org AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company

  4. 02/28/11 – Reviewed 02/27/12 – Reviewed 02/25/13 – Approvable dx question 04/08/13 – Updated 07/29/13 – Updated 08/26/13 – Updated 10/21/13 – Updated 11/04/13 – Updated 01/13/14 – Retin-A micro gel & Metrogel 1% generics 02/24/14 – Updated 05/05/14 – Differin generic 02/23/15 – Reviewed 09/18/17 – Updated 02/26/18 – Updated 02/20/19 – Updated 07/2019 – Removed references to Finacea foam (nonformulary) Disclaimer AllWays Health Partners complies with applicable federal civil rights laws and does not discriminate or exclude people on the basis of race, color, national origin, age, disability, or sex. 399 Revolution Drive, Suite 810, Somerville, MA 02145 | allwayshealthpartners.org AllWays Health Partners includes AllWays Health Partners, Inc. and AllWays Health Partners Insurance Company