roflumilast 0.3% topical foam — Medica

Preferred products

• Betamethasone dipropionate (various strengths and forms as in Table 1)
• Clobetasol propionate (various strengths and forms as in Table 1)
• Fluocinonide (various strengths and forms as in Table 1)
• Halobetasol propionate (various strengths and forms as in Table 1)
• Amcinonide 0.1%
• Desoximetasone (various strengths and forms as in Table 1)
• Diflorasone diacetate 0.05%
• Halcinonide 0.1%
• Betamethasone valerate 0.1%
• Fluticasone propionate 0.005% ointment
• Mometasone furoate (0.1% ointment, cream, lotion, solution)
• Triamcinolone acetonide (0.5%, 0.1%, or 0.05% formulations)
• Fluocinolone acetonide 0.025% ointment
• Clocortolone pivalate 0.1% cream
• Hydrocortisone valerate 0.2% ointment
• Flurandrenolide (4 mcg/m2 tape, 0.05% ointment)

Initial criteria

• Approve if patient has tried one Step 1 Product (one topical corticosteroid from Groups 1–4 as listed in Table 1); OR
• If treating seborrheic dermatitis, approve if patient meets ONE of the following: tried one prescription topical corticosteroid (brand or generic); OR tried a combination product containing a topical corticosteroid; OR tried one topical antifungal (ketoconazole 2% cream/foam/shampoo, ciclopirox 0.77% cream/gel, or ciclopirox 1% shampoo); OR tried a combination product containing a topical antifungal; OR
• If treating plaque psoriasis, approve if patient meets ONE of the following: tried one topical vitamin D analog (calcipotriene 0.005% cream/foam/ointment/solution, calcitriol 3 mcg/g ointment [Vectical], Sorilux); OR tried one combination product containing a topical vitamin D analog and topical corticosteroid (calcipotriene 0.005% and betamethasone dipropionate 0.064% ointment/suspension [Taclonex, generic], Enstilar, Wynzora); OR patient is treating plaque psoriasis affecting face, eyes/eyelids, skin folds, and/or genitalia.

Approval duration

1 year