Zoryve — Blue Cross Blue Shield of Kansas

Initial criteria

• Patient has a diagnosis of mild to moderate atopic dermatitis (AD)
• AND ONE of the following:
• • 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
• • Patient has an intolerance or hypersensitivity to at least a low-potency topical corticosteroid used in the treatment of AD OR
• • Patient has an FDA labeled contraindication to ALL topical corticosteroids used in the treatment of AD
• AND ONE of the following:
• • 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
• • Patient has an intolerance or hypersensitivity to a topical calcineurin inhibitor used in the treatment of AD OR
• • Patient has an FDA labeled contraindication to ALL topical calcineurin inhibitors used in the treatment of AD
• AND BOTH of the following:
• • Patient is currently treated with topical emollients and practicing good skin care
• • Patient will continue the use of topical emollients and good skin care practices in combination with the requested agent