roflumilast foam — Blue Cross Blue Shield of Alabama

Initial criteria

• Patient has diagnosis of plaque psoriasis AND ALL of the following:
• • Affected body surface area (BSA) ≤20%
• AND ONE of the following:
• • Tried and had an inadequate response to a topical corticosteroid after ≥2 weeks OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL topical corticosteroids
• AND ONE of the following:
• • Tried and had an inadequate response to another topical psoriasis agent with a different mechanism of action (e.g., vitamin D analogs, calcineurin inhibitors, tazarotene) OR intolerance/hypersensitivity OR FDA labeled contraindication to ALL other topical psoriasis agents with a different mechanism of action
• 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

12 months