Zoryve Foam (roflumilast 0.3% topical foam − Arcutis) — Medical Mutual

Initial criteria

• Approve for 1 year if patient has an atypical diagnosis and/or unique patient characteristics which prevent use of all preferred agents
• OR Approve for 1 year if patient has a contraindication to all preferred agents
• OR Approve for 1 year if patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following: (a) patient has at least 130 days of prescription claims history on file and claims history supports patient has received requested non-preferred agent for 90 days within a 130-day look-back period AND there is no generic equivalent available for requested non-preferred product; OR (b) when 130 days of prescription claims history file is unavailable, prescriber must verify that patient has been receiving the requested non-preferred agent for 90 days via paid claims (not samples/coupons/waivers) AND there is no generic equivalent available for requested non-preferred product

Approval duration

1 year