Wynzora — Medical Mutual

Plaque psoriasis

Preferred products

If the patient has tried a preferred medication, then authorization for a non-preferred medication may be given.
If the patient is < 18 years of age, approve generic calcipotriene-betamethasone dipropionate ointment, Taclonex ointment, calcipotriene foam (authorized generic), Enstilar, or Sorilux.

Step Therapy Exception Criteria: Approve for 1 year if the patient meets the following (A, B, or C):
A. The patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents. OR
B. The patient has a contraindication to all preferred agents. OR
C. The patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following:
1. The patient has at least 130 days of prescription claims history on file and claims history supports that the patient has received the requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for the requested nonpreferred product (i.e. AA-rated or AB-rated to the requested nonpreferred product). OR
2. When 130 days of the patient’s prescription claims history file is unavailable for verification, the prescriber must verify that the patient has been receiving the requested non-preferred agent for 90 days AND that the patient has been receiving the requested non-preferred agent via paid claims AND there is no generic equivalent available for the requested nonpreferred product (i.e. AA-rated or AB-rated to the requested nonpreferred product).

initial 1 year; extended 2 years; continuation 1 year