Subject: Arazlo PA 3496-A P08-2024_R

Drug

ARAZLO  (tazarotene)

Policy:

Indications

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

Acne Vulgaris
Authorization may be granted when the requested drug is being prescribed for the topical treatment of acne vulgaris

Continuation of Therapy

Acne Vulgaris
Authorization may be granted when the requested drug is being prescribed for the topical treatment of acne vulgaris when the following criteria is met:

• The patient has achieved or maintained a positive clinical response as evidenced by improvement (e.g., reduction in number of lesions, patient satisfaction, etc.)

Duration of Approval (DOA)

• 3496-A: Initial therapy DOA: 4 months; Continuation of therapy DOA: 36 months

Place of Service:

Outpatient

The above policy is based on the following references:

1. Arazlo [package insert]. Bridgewater, NJ: Bausch Health US, LLC; August 2023.
2. Lexicomp Online, Lexi-Drugs Online, Hudson, OH: UpToDate, Inc.; 2024; Accessed July 17, 2024.
3. Micromedex® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 07/17/2024).
4. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5): 1006.e1-1006.e30.

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.

December 19, 2024