roflumilast cream — Blue Cross Blue Shield of Alabama

Initial criteria

• Patient has diagnosis of mild to moderate atopic dermatitis (AD) AND ALL of the following:
• ONE of the following:
• • Tried and had an inadequate response to at least a low-potency topical corticosteroid after ≥4 weeks OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL topical corticosteroids
• AND ONE of the following:
• • Tried and had an inadequate response to a topical calcineurin inhibitor after ≥6 weeks OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL topical calcineurin inhibitors
• AND BOTH of the following:
• • Currently treated with topical emollients and practicing good skin care
• • Will continue use of topical emollients and good skin care with requested agent
• Prescriber is specialist in area of diagnosis or has consulted a specialist
• Patient does NOT have FDA labeled contraindications

Reauthorization criteria

• Previously approved for the requested agent through plan’s PA process
• Has had clinical benefit with requested agent
• Prescriber is specialist in area of diagnosis or has consulted a specialist
• No FDA labeled contraindications

Approval duration

3 months