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