Pharmacy Prior Authorization Criteria

Skin Cancer Agents

Indications for Prior Authorization

Klisyri (tirbanibulin) ointment

• For diagnosis of Actinic Keratosis
  indicated for the topical treatment of actinic keratosis on the face or scalp.

Criteria

Klisyri

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure, contraindication, or intolerance to both of the following generics:
• fluorouracil
• imiquimod

P & T Revisions

2024-07-30, 2024-03-25, 2023-04-04, 2022-04-05, 2021-06-21, 2021-05-11, 2021-03-03, 2020-04-29

References

1. American Academy of Dermatology. Actinic Keratosis: diagnosis and treatment. https://www.aad.org/public/diseases/scaly-skin/actinic-keratosis#treatment. Accessed March 25, 2024.
2. Klisyri Prescribing Information. Almirall, LLC. Exton, PA. November 2023.

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Revision History

• 2024-07-30: Removal of Diclofenac sodium gel 3% as target from guideline
• 2024-03-25: 2024 Annual Review. Updated references.
• 2023-04-04: Annual review - picato discontinued and will be obsolete 4/8/2023 - removed product. Updated background and references.
• 2022-04-05: Annual review - added diagnosis statement and updated references.
• 2021-06-21: Updated guideline
• 2021-05-11: 2021 Annual Review
• 2021-03-03: Added Klisyri as target
• 2020-04-29: Annual Review

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