Opzelura (ruxolitinib cream) — CareFirst (Caremark)
Nonsegmental vitiligo
Initial criteria
- Drug is prescribed for nonsegmental vitiligo
- Drug is NOT prescribed in combination with therapeutic biologics, other janus kinase (JAK) inhibitors, or potent immunosuppressants such as azathioprine or cyclosporine
- Patient age ≥ 12 years
- Drug will NOT be applied to affected areas > 10% body surface area (BSA)
- If additional quantities are requested, drug is prescribed to treat a body surface area that requires more than 60 grams per 28 days
Reauthorization criteria
- Drug is prescribed for nonsegmental vitiligo
- Drug is NOT prescribed in combination with therapeutic biologics, other janus kinase (JAK) inhibitors, or potent immunosuppressants such as azathioprine or cyclosporine
- Patient age ≥ 12 years
- Patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., meaningful repigmentation)
- Drug will NOT be applied to affected areas > 10% BSA
- If additional quantities are requested, drug is prescribed to treat a body surface area that requires more than 60 grams per 28 days
Approval duration
Initial: 7 months; Reauthorization: 12 months