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The Policy VaultThe Policy Vault

Zoryve — Blue Cross Blue Shield of Kansas

seborrheic dermatitis

Initial criteria

  • 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 seborrheic dermatitis AND BOTH of the following:
  • 1. ONE of the following:
  • A. The patient has tried and had an inadequate response to ONE topical antifungal OR ONE topical corticosteroid used in the treatment of seborrheic dermatitis OR
  • B. The patient has an intolerance or hypersensitivity to ONE topical antifungal OR ONE topical corticosteroid used in the treatment of seborrheic dermatitis OR
  • C. The patient has an FDA labeled contraindication to ALL topical antifungals AND topical corticosteroids used in the treatment of seborrheic dermatitis AND
  • 2. ONE of the following:
  • A. The patient has seborrheic dermatitis of the scalp OR
  • B. The patient has tried and had an inadequate response to ONE topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) used in the treatment of seborrheic dermatitis OR
  • C. The patient has an intolerance or hypersensitivity to ONE topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) used in the treatment of seborrheic dermatitis OR
  • D. The patient has an FDA labeled contraindication to ALL topical calcineurin inhibitors used in the treatment of seborrheic dermatitis 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 BOTH of the following:
  • A. ONE of the following:
  • 1. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
  • 2. There is support for using the requested agent for the patient’s age for the requested indication AND
  • B. The requested dosage form and strength of Zoryve is FDA labeled for the requested indication AND
  • The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis 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 a specialist in the area of the patient’s diagnosis
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months for plaque psoriasis; 3 months for atopic dermatitis or seborrheic dermatitis; 12 months for all other labeled indications; 12 months renewal