Klisyri (tirbanibulin) — Highmark

Preferred products

• imiquimod 5% cream
• fluorouracil 5% cream
• fluorouracil solution

Initial criteria

• age ≥ 18 years
• diagnosis of actinic keratosis (AK) of the face or scalp (ICD-10 L57.0)
• therapeutic failure or intolerance to one of the following plan-preferred generic topical agents OR contraindication to all: imiquimod 5% cream, fluorouracil 5% cream, fluorouracil solution

Reauthorization criteria

• prescriber attests member previously experienced complete or partial clearance of AK lesions with Klisyri
• prescriber attests an additional course of therapy is required for recurrence of AK
• member is restarting therapy at least 60 days after cessation of an initial Klisyri 5-day course

Approval duration

1 month