Subject: Arazlo PA Policy 3496-A UDR 04-2023

Drug

ARAZLO  (tazarotene lotion)

Policy:

FDA-APPROVED INDICATIONS
Arazlo (tazarotene) lotion, 0.045% is indicated for the topical treatment of acne vulgaris in patients 9 years of age and older.

COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
     •   The patient has a diagnosis of acne vulgaris

Place of Service:

Outpatient

The above policy is based on the following references:

1. Arazlo [package insert]. Bridgewater, NJ: Bausch Health US, LLC; May 2021.
2. Lexicomp Online, Lexi-Drugs Online, Hudson, OH: UpToDate, Inc.; 2023; Accessed February 23, 2023.
3. Micromedex (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 02/23/2023).
4. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74:945-73.

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.

August 13, 2023