DUOBRII (halobetasol propionate and tazarotene)

DUOBRII (halobetasol propionate and tazarotene)

SELF ADMINISTRATION - Topical

Indications for Prior Authorization:

• Indicated for the topical treatment of plaque psoriasis in adults.

Patients must meet the following criteria for the indication(s) above:

• Initial therapy request:
  • Diagnosis of plaque psoriasis (chart notes required) with body surface area involvement less than or equal to 20%, AND
  • Patient is 18 years of age or older, AND
  • Prescribed by or in consultation with a dermatologist, AND
  • Failure of generic halobetasol propionate and generic clobetasol propionate, AND
  • Failure of generic tazarotene, AND
  • Request does not exceed 200 grams per month (two tubes per month)
  • Approval duration: 8 weeks
• Continued therapy request:
  • For plaque psoriasis:
    • Currently receiving medication or patient has previously met initial approval criteria, AND
    • Current chart note documentation supports patient is responding positively to therapy, AND
    • If request is for a dose/quantity increase, new dose does not exceed 200 grams per month (two tubes per month)

Diagnoses/Indications for which coverage is NOT authorized:

• Non-FDA approved indications unless sufficient evidence based documentation support of efficacy and safety in accordance with off-label use policy.

Dosing:

• Apply a thin layer once daily to cover only affected areas and rub in gently.  If a bath or shower is taken prior to application, the skin should be dry before applying the lotion.
• Total dosage should not exceed approximately 50 grams per week because of the potential for the drug to suppress the hypothalamic-pituitary-adrenal (HPA) axis.
• Discontinue treatment when control is achieved.
• Avoid application to the face, groin or in the axillae