Opzelura — Medical Mutual

Vitiligo

Initial criteria

Patient is age ≥ 12 years
Patient has nonsegmental vitiligo
Patient has vitiligo involvement estimated to affect ≤ 10% of the body surface area
Patient meets ONE of the following (i or ii):
i. Patient meets ALL the following criteria (a, b, and c):
a) Patient has tried at least one high-, and/or super-high-potency prescription topical corticosteroid; AND
b) The duration of this topical corticosteroid therapy was at least 12 weeks; AND
c) Inadequate efficacy was demonstrated with this topical corticosteroid therapy, according to the prescriber; OR
ii. Patient is treating vitiligo affecting one of the following areas: face, eyes/eyelids, skin folds, and/or genitalia
Patient meets ALL the following (i, ii, and iii):
i. Patient has tried at least one topical calcineurin inhibitor; AND
ii. This topical calcineurin inhibitor was applied daily for at least 12 weeks; AND
iii. Inadequate efficacy was demonstrated with this topical calcineurin inhibitor, according to the prescriber
The medication is prescribed by or in consultation with a dermatologist

Response to therapy is required for continuation of therapy unless otherwise noted

6 months