Opzelura (ruxolitinib) — Highmark

Preferred products

• high potency topical corticosteroid
• ultrahigh potency topical corticosteroid

Initial criteria

• age ≥ 12 years
• diagnosis of vitiligo (ICD-10: L80), classified as nonsegmental
• prescriber attests that body surface area (BSA) with vitiligo involvement does not exceed 10%
• member meets one (1) of the following: (a) therapeutic failure or intolerance to at least one generic, formulary high or ultrahigh potency topical corticosteroid OR (b) vitiligo with facial or anogenital involvement

Reauthorization criteria

• prescriber attests that the member has experienced meaningful repigmentation of affected areas

Approval duration

initial up to 24 weeks, reauthorization up to 12 months