Pharmacy Prior Authorization Criteria

Duobrii (halobetasol propionate and tazarotene) - PA, NF

Indications for Prior Authorization

Duobrii (halobetasol propionate and tazarotene)

• For diagnosis of Plaque Psoriasis
  Indicated for the topical treatment of plaque psoriasis in adults.

Criteria

Duobrii

Prior Authorization

Length of Approval: 12 Month(s)

• Diagnosis of plaque psoriasis
AND
• Prescribed by or in consultation with a dermatologist
AND
• Trial and failure, intolerance, or contraindication to ALL of the following:
• One high potency corticosteroid topical treatment (e.g., halobetasol propionate, clobetasol propionate, fluocinonide)
• Tazarotene
• Enstilar foam, Wynzora, Taclonex suspension/ointment, or generic Taclonex

Duobrii

Non Formulary

Length of Approval: 12 Month(s)

• Diagnosis of plaque psoriasis
AND
• Prescribed by or in consultation with a dermatologist
AND
• Paid claims or submission of medical records (e.g., chart notes) confirming a trial and failure, intolerance or contraindication to ALL of the following:
• One high potency corticosteroid topical treatment (e.g., halobetasol propionate, clobetasol propionate, fluocinonide)
• Tazarotene
• Enstilar foam, Wynzora, Taclonex suspension/ointment, or generic Taclonex

P & T Revisions

2024-07-03, 2023-07-06, 2022-11-04, 2022-07-21, 2021-06-15, 2020-06-30

References

1. Duobrii Prescribing Information. Bausch Health Americas, Inc. Bridgewater, NJ. January 2020.
2. Elmets CA, Korman NJ, Farley Prater E, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol 2021;84:432-70.
3. Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023; Epub ahead of print.

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Revision History

• 2024-07-03: Annual review - no criteria changes; background updates
• 2023-07-06: Annual review - no criteria changes; background updates
• 2022-11-04: Updated to a triple step (added a ST through Enstilar Foam, Wynzora, Taclonex Susp/Oint or generic Taclonex)
• 2022-07-21: Annual review - updated references.
• 2021-06-15: Annual review - updated references.
• 2020-06-30: Annual review - updated references.

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