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Vtama — Blue Cross Blue Shield of Alabama

other FDA labeled indications

Initial criteria

  • ONE of the following:
  • - The patient has a diagnosis of plaque psoriasis AND ALL of the following:
  • • The patient's affected body surface area (BSA) ≤ 20%
  • • ONE of the following:
  • – The patient has tried and had an inadequate response to a topical corticosteroid used in the treatment of plaque psoriasis after at least a 2-week duration of therapy OR
  • – The patient has an intolerance or hypersensitivity to therapy with a topical corticosteroid used in the treatment of plaque psoriasis OR
  • – The patient has an FDA labeled contraindication to ALL topical corticosteroids used in the treatment of plaque psoriasis
  • • ONE of the following:
  • – The patient has 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
  • – The patient has an intolerance or hypersensitivity to another topical psoriasis agent with a different mechanism of action OR
  • – The patient has an FDA labeled contraindication to ALL other topical psoriasis agents with a different mechanism of action
  • OR
  • - The patient has a diagnosis of atopic dermatitis (AD) AND ALL of the following:
  • • ONE of the following:
  • – The patient has tried and had an inadequate response to at least a low-potency topical corticosteroid used in the treatment of AD after at least a 4-week duration of therapy OR
  • – The patient has an intolerance or hypersensitivity to at least a low-potency topical corticosteroid used in the treatment of AD OR
  • – The patient has an FDA labeled contraindication to ALL topical corticosteroids used in the treatment of AD
  • • ONE of the following:
  • – The patient has tried and had an inadequate response to a topical calcineurin inhibitor used in the treatment of AD after at least a 6-week duration of therapy OR
  • – The patient has an intolerance or hypersensitivity to a topical calcineurin inhibitor used in the treatment of AD OR
  • – The patient has an FDA labeled contraindication to ALL topical calcineurin inhibitors used in the treatment of AD
  • • BOTH of the following:
  • – The patient is currently treated with topical emollients and practicing good skin care AND
  • – The patient will continue the use of topical emollients and good skin care practices in combination with the requested agent
  • OR
  • - The patient has another FDA labeled indication for the requested agent and route of administration
  • AND If the patient has an FDA labeled indication, then ONE of the following:
  • • The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • • There is support for using the requested agent for the patient’s age for the requested indication
  • AND
  • - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist) or has consulted with one
  • AND
  • - The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
  • The patient has had clinical benefit with the requested agent
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist) or has consulted with one
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

3 months for atopic dermatitis; 12 months for plaque psoriasis and all other indications (renewal 12 months)