Hyftor (sirolimus) topical gel
Indications for Prior Authorization
Hyftor (sirolimus) topical gel
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For diagnosis of Facial Angiofibroma
Indicated for the treatment of facial angiofibroma associated with tuberous sclerosis in adults and pediatric patients 6 years of age and older.
Criteria
Hyftor
Prior Authorization (Initial Authorization)
Length of Approval: 4 Month(s) [A]
- Diagnosis of facial angiofibroma associated with tuberous sclerosis complex AND
- Patient is 6 years of age or older AND
- Patient is not a candidate for laser therapy or surgical treatments AND
- Prescribed by or in consultation with one of the following:
- dermatologist
- neurologist
- geneticist
Hyftor
Prior Authorization (Reauthorization)
Length of Approval: 12 Month(s)
- Patient demonstrates positive clinical response to therapy.(e.g., improvement in size or redness of facial angiofibroma)
P & T Revisions
2023-12-29, 2023-11-02, 2023-10-05, 2023-02-01, 2022-09-06
References
- Hyftor Prescribing Information. Nobelpharma America, LLC. Bethesda, MD. March 2022.
End Notes
- If symptoms do not improve within 12 weeks of treatment, patient should be re-evaluated to determine the need to continue treatment. An additional month is added to the initial authorization duration to allow for patient follow-up with the provider. [1]
Revision History
- 2023-12-29: Annual review. No changes to clinical criteria.
- 2023-11-02: Program update to standard reauthorization language. No changes to clinical intent.
- 2023-10-05: 2023 Annual Review - No changes to criteria
- 2023-02-01: Update prescriber requirement options to include neurologist and geneticist.
- 2022-09-06: New program for Hyftor.
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