Pharmacy Prior Authorization Criteria

Vtama (tapinarof)

Indications for Prior Authorization

Vtama (tapinarof) cream

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

• For diagnosis of Atopic Dermatitis (AD)
  Indicated for the topical treatment of atopic dermatitis in adults and pediatric patients 2 years of age and older.

Criteria

Vtama

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Plaque Psoriasis (PsO)

• Diagnosis of plaque psoriasis
AND
• Minimum duration of a 4-week trial and failure, contraindication, or intolerance to ONE of the following generic topical therapies [2]:
• Corticosteroids (e.g., betamethasone, clobetasol)
• Vitamin D analogs (e.g., calcitriol, calcipotriene)
• Tazarotene
• Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus)
• Combination topical therapy (e.g., vitamin D analog/corticosteroid)
AND
• Prescribed by or in consultation with a dermatologist

Vtama

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Plaque Psoriasis (PsO)

• Patient demonstrates positive clinical response to therapy as evidenced by one of the following [1-2]:
• Reduction in the body surface area (BSA) involvement from baseline
• Improvement in symptoms (e.g., pruritus, inflammation) from baseline

Vtama

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of Atopic Dermatitis (AD)

• Diagnosis of atopic dermatitis
AND
• Patient is 2 years of age or older
AND
• Prescribed by or in consultation with one of the following:
• Allergist/Immunologist
• Dermatologist
AND
• Trial and failure of a minimum 30-day supply (14-day supply for topical corticosteroids), contraindication, or intolerance to ONE of the following:
• Medium or higher potency topical corticosteroid
• Generic topical calcineurin inhibitor (e.g., tacrolimus ointment)

Vtama

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Atopic Dermatitis (AD)

• Patient demonstrates positive clinical response to therapy as evidenced by ONE of the following [1, 3]:
• Reduction in body surface area involvement from baseline
• Reduction in pruritus severity from baseline
• Improvement in quality of life from baseline

P & T Revisions

2025-03-05, 2025-02-09, 2024-09-08, 2024-07-03, 2023-12-01, 2023-07-06, 2022-11-03, 2022-07-13, 2022-07-14

References

1. Vtama Prescribing Information. Dermavant Sciences Inc. Long Beach, CA. May 2022.
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;89(1):e1-e20.

---

Revision History

• 2025-03-05: Addition of criteria for atopic dermatitis
• 2025-02-09: Addition of criteria for atopic dermatitis; added Zoryve 0.3% as an additional preferred alternative for plaque psoriasis; updated the plaque psoriasis criteria to increase from a single step to a double step
• 2024-09-08: Removed anthralin and coal tar as topical step options for PsO
• 2024-07-03: Annual review - no criteria changes; background updates
• 2023-12-01: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-07-06: Annual review - no criteria changes
• 2022-11-03: Updated step to a single generic topical agent
• 2022-07-13: New program
• 2022-07-14: New program

---