tapinarof cream 1 % — Blue Cross Blue Shield of Texas

Initial criteria

• ONE of the following:
• A. Diagnosis of plaque psoriasis AND BOTH of the following:
• 1. Affected body surface area (BSA) ≤ 20% AND
• 2. ONE of the following:
• A. Tried and had an inadequate response to a topical corticosteroid or topical calcineurin inhibitor used in the treatment of plaque psoriasis after at least a 2-week duration of therapy OR
• B. Intolerance or hypersensitivity to therapy with topical corticosteroids or topical calcineurin inhibitors used in the treatment of plaque psoriasis OR
• C. FDA labeled contraindication to ALL topical corticosteroids and ALL topical calcineurin inhibitors used in the treatment of plaque psoriasis
• B. Diagnosis of atopic dermatitis (AD) AND BOTH of the following:
• 1. ONE of the following:
• A. Tried and had an inadequate response to at least a low-potency topical corticosteroid or topical calcineurin inhibitor or topical emollients used in treatment of AD after at least a 4-week duration of therapy OR
• B. Intolerance or hypersensitivity to therapy with low-potency topical corticosteroid or topical calcineurin inhibitor used in treatment of AD OR
• C. FDA labeled contraindication to ALL low-potency topical corticosteroid or topical calcineurin inhibitor used in treatment of AD AND
• 2. BOTH of the following:
• A. Patient is currently treated with topical emollients and practicing good skin care AND
• B. Patient will continue the use of topical emollients and good skin care practices in combination with the requested agent
• C. Another FDA labeled indication for the requested agent and route of administration
• If patient has an FDA labeled indication, then ONE of the following:
• A. Age is within FDA labeling for the requested indication for the requested agent OR
• B. Support for using the requested agent for the patient's age for the requested indication
• 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
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Patient has had clinical benefit with the requested agent
• 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
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months