Subject: Psoriasis Agents

Status	Drug	PR	PR-QL	PR-AL	ST	M EX‡
P	augmented betamethasone dipropionate
P	betamethasone
P	calcipotriene
P	Soriatane®  (acitretin)
P	Soriatane CK Kit®  (acitretin cap w/ Moisturizer Kit)
P	Tazorac®  (tazarotene)			X
P	Vectical™  (calcitriol)
FE	Dovonex®  (calcipotriene)					X
FE	Taclonex®  (calcipotriene-betamethasone dipropionate)					X

Policy:

1. Precertification Criteria

Under some plans, including plans that use an open or closed formulary, Tazorac is subject to precertification for members greater than 35 years of age. If precertification requirements apply Aetna considers Tazorac to be medically necessary for those members who meet any of the following precertification criteria:

A. A documented diagnosis of acne vulgaris

OR

B. A documented diagnosis of plaque psoriasis

2. Medical Exception Criteria

Dovonex and Taclonex are currently listed on the Aetna Formulary Exclusions List.* Therefore, Dovonex and Taclonex are excluded from coverage for members enrolled in prescription drug benefits plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Dovonex and Taclonex to be medically necessary for those members who meet any of the following criteria:

For Dovonex (A OR B)

A. A documented:

• Contraindication to the preferred alternative Tazorac OR
• Intolerance to the preferred alternative Tazorac OR
• Allergy to the preferred alternative Tazorac OR
• Failure of an adequate trial of one month of the preferred alternative Tazorac
• Member is pregnant (Dovonex is a pregnancy Category C) OR

B.   Member is documented to have been successfully treated with calcipotriene
       in the past.-For Dovonex oint/cream only 

For Taclonex

A. A documented:

• Contraindication to the preferred alternative Tazorac or calcipotriene solution OR
• Intolerance to the preferred alternative Tazorac or calcipotriene solution OR
• Allergy to the preferred alternative Tazorac or calcipotriene solution OR
• Failure of one month concurrent use of Tazorac or calcipotriene solution AND topical betamethasone

Place of Service:

Outpatient

The above policy is based on the following references:

1. DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically.
2. AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
3. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
4. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
5. PDR® Electronic Library™ [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
6. Clinical Pharmacology [Internet database]. Gold Standard Inc. Tampa, FL. Updated periodically.
7. van de Kerkhof PC, Wasel N, Kragballe K, Cambazard F, Murray S. A two-compound product containing calcipotriol and betamethasone dipropionate provides rapid, effective treatment of psoriasis vulgaris regardless of baseline disease severity. Dermatology. 2005;210(4):294-9.
8. Gladman DD. Traditional and newer therapeutic options for psoriatic arthritis: an evidence-based review. Drugs. 2005;65(9):1223-38.
9. Lebwohl M, Menter A, Weiss J, et al. Calcitriol 3µg/g ointment in the management of mild-to-moderate plaque type psoriasis: results from two placebo controlled, multicenter, randomized investigator–blinded clinical studies. J Drugs Derm. 2007;6(4):428-35.
10. Guidelines of care for the management of psoriasis and psoriatic arthritis Journal of the American Academy of Dermatology - Volume 58, Issue 5 (May 2008)  -  Copyright © 2008 American Academy of Dermatology, Inc
11. Mason AR, Mason J, Cork M et al. Topical treatments for chronic plaque psoriasis. Cochrane Database System Review 2009;15:CD005028.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

January 01, 2010