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Zoryve — Blue Cross Blue Shield of New Mexico

mild to moderate atopic dermatitis

Initial criteria

  • ONE of the following:
  • A. The patient has a diagnosis of mild to moderate atopic dermatitis (AD) AND ALL of the following:
  • 1. ONE of the following: - Tried and had an inadequate response to at least a low-potency topical corticosteroid used in AD after ≥4 weeks OR - Intolerance or hypersensitivity to a low-potency topical corticosteroid used in AD OR - FDA labeled contraindication to ALL topical corticosteroids used in AD
  • 2. ONE of the following: - Tried and had an inadequate response to a topical calcineurin inhibitor used in AD after ≥6 weeks OR - Intolerance or hypersensitivity to a topical calcineurin inhibitor used in AD OR - FDA labeled contraindication to ALL topical calcineurin inhibitors used in AD
  • 3. BOTH of the following: - Patient is currently treated with topical emollients and practicing good skin care AND - Will continue use of topical emollients and good skin care in combination with the requested agent
  • OR
  • B. The patient has a diagnosis of plaque psoriasis AND BOTH of the following:
  • 1. Affected body surface area ≤20%
  • 2. ONE of the following: - Tried and had an inadequate response to a topical corticosteroid (≥2-week duration) or a topical calcineurin inhibitor OR - Intolerance or hypersensitivity to a topical corticosteroid or calcineurin inhibitor OR - FDA labeled contraindication to ALL topical corticosteroids AND ALL topical calcineurin inhibitors
  • OR
  • C. The patient has a diagnosis of seborrheic dermatitis AND ONE of the following:
  • 1. BOTH of the following: A. ONE of the following: - Prescriber has stated or documented that patient has stage 4 advanced, metastatic cancer and requested agent is used to treat the cancer OR - Prescriber has submitted documentation that patient has stage 4 advanced, metastatic cancer and drug is used for an associated condition (chart notes required) B. Use is consistent with best practices, supported by evidence-based literature, and FDA-approved
  • OR
  • 2. BOTH of the following: 1. ONE of the following: - Tried and had an inadequate response to ONE topical antifungal OR ONE topical corticosteroid used in seborrheic dermatitis OR - Intolerance or hypersensitivity to ONE topical antifungal OR ONE topical corticosteroid used in seborrheic dermatitis OR - FDA labeled contraindication to ALL topical antifungals AND corticosteroids used in seborrheic dermatitis 2. ONE of the following: - Seborrheic dermatitis of the scalp OR - Tried and had an inadequate response to ONE topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) used in seborrheic dermatitis OR - Intolerance or hypersensitivity to ONE topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) used in seborrheic dermatitis OR - FDA labeled contraindication to ALL topical calcineurin inhibitors used in seborrheic dermatitis
  • OR
  • D. The patient has another FDA labeled indication for the requested agent and route of administration AND BOTH of the following:
  • A. ONE of the following: - Patient’s age is within FDA labeling for the requested indication OR - There is support for use at the patient’s age for that indication
  • B. Requested dosage form and strength of Zoryve is FDA labeled for the requested indication
  • AND
  • Prescriber is a specialist in the area of the diagnosis (e.g., dermatologist) or has consulted with such a specialist
  • AND
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Additional approval path (Ohio residents, Fully Insured or HIM Shop plan): - Member resides in Ohio AND - Plan is Fully Insured or HIM Shop (SG) AND BOTH: a. Patient has no FDA labeled contraindications AND b. ONE of the following: i. Patient has another FDA labeled indication for requested agent and route OR ii. Patient has another indication supported in compendia for requested route OR iii. Prescriber submitted two articles from major peer-reviewed journals supporting proposed use (randomized, double-blind, placebo-controlled; not case studies)

Reauthorization criteria

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

Approval duration

12 months