Pharmacy Prior Authorization Criteria

Topical Rosacea Agents

Indications for Prior Authorization

Zilxi (minocycline) foam, Epsolay (benzoyl peroxide) cream

• For diagnosis of Rosacea
  Indicated for the treatment of inflammatory lesions of rosacea in adults.

Finacea (azelaic acid) gel

• For diagnosis of Rosacea
  Indicated for topical treatment of the inflammatory papules and pustules of mild to moderate rosacea.

  Efficacy for treatment of erythema in rosacea in the absence of papules and pustules has not been evaluated.

Noritate (metronidazole) cream

• For diagnosis of Rosacea
  Indicated for the topical treatment of inflammatory lesions and erythema of rosacea.

Metrogel (metronidazole) gel

• For diagnosis of Rosacea
  Indicated for the topical treatment of inflammatory lesions of rosacea.

Rhofade (oxymetazoline hydrochloride) cream

• For diagnosis of Rosacea
  Indicated for the topical treatment of persistent facial erythema associated with rosacea in adults.

Criteria

Epsolay Cream, Brand Finacea Gel, Zilxi Foam, Noritate Cream

Step Therapy

Length of Approval: 12 Month(s)

• Trial and failure (of a minimum 30-day supply), contraindication or intolerance to one of the following:
• azelaic acid gel
• Soolantra cream
• Finacea foam

Brand Metrogel

Step Therapy

Length of Approval: 12 Month(s)

• Trial and failure (of a minimum 30-day supply), contraindication or intolerance to one of the following:
• generic metronidazole gel
• Soolantra cream
• Finacea foam

Rhofade

Step Therapy

Length of Approval: 12 Month(s)

• Trial and failure (of a minimum 30-day supply), contraindication or intolerance to Mirvaso (brimonidine gel)

P & T Revisions

2024-07-09, 2024-04-02, 2022-07-26, 2022-07-06, 2021-07-02, 2021-01-06, 2020-11-19, 2020-10-14, 2020-07-28

References

1. Zilxi Prescribing Information. Vyne Pharmaceuticals Inc. Bridgewater, NJ. September 2022.
2. Finacea Gel Prescribing Information. Bayer HealthCare Pharmaceuticals Inc. Whippany, NJ. November 2021.
3. Noritate Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. June 2020.
4. Metrogel Prescribing Information. Galderma Laboratories, L.P. Fort Worth, TX. November 2023.
5. Epsolay Prescribing Information. Galderma Laboratories, LP. Fort Worth, TX. April 2023.
6. Rhofade Prescribing Information. Allergan, Inc. Irvine, CA. November 2018.

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Revision History

• 2024-07-09: 2024 Annual Review, updated references.
• 2024-04-02: Added Rhofade as target to the guideline.
• 2022-07-26: 2022 Annual Review
• 2022-07-06: Added Epsolay. Updated background and references.
• 2021-07-02: 2021 Annual Review
• 2021-01-06: Combined and streamlined criteria for Brand Finacea Gel, Noritate and Zilxi.
• 2020-11-19: Added step therapy criteria for Brand Finacea Gel, Noritate and Brand Metrogel. Modified Zilxi ST to include additional T/F option.
• 2020-10-14: Removed 180-day lookback as ST has a lifetime lookback
• 2020-07-28: New program.

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