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The Policy VaultThe Policy Vault

Tazorac (tazarotene 0.05% cream, 0.05% gel, 0.1% cream, 0.1% gel) — Cigna

Other non-cosmetic skin conditions (e.g., acne keloidalis nuchae, basal cell carcinoma, comedonal acne, cystic acne, cutaneous T-cell lymphoma, ichthyosis, keratoderma blennorrhagicum, keratosis including keratosis follicularis [Darier’s disease] and keratosis pilaris, mycosis fungoides, nail psoriasis, oral lichen planus, warts)

Initial criteria

  • Patient has a diagnosis of acne vulgaris OR plaque psoriasis OR other non-cosmetic condition supported by evidence
  • Request is not for cosmetic use (e.g., wrinkles, photo-aged or photo-damaged skin, melasma, etc.)

Approval duration

1 year