Pharmacy Prior Authorization Criteria

Hyftor (sirolimus) topical gel

Indications for Prior Authorization

Hyftor (sirolimus) topical gel

• For diagnosis of Facial Angiofibroma
  Indicated for the treatment of facial angiofibroma associated with tuberous sclerosis in adults and pediatric patients 6 years of age and older.

Criteria

Hyftor

Prior Authorization (Initial Authorization)

Length of Approval: 4 Month(s) [A]

• Diagnosis of facial angiofibroma associated with tuberous sclerosis complex
AND
• Patient is 6 years of age or older
AND
• Patient is not a candidate for laser therapy or surgical treatments
AND
• Prescribed by or in consultation with one of the following:
• dermatologist
• neurologist
• geneticist

Hyftor

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy.(e.g., improvement in size or redness of facial angiofibroma)

P & T Revisions

2025-01-20, 2023-12-29, 2023-11-02, 2023-10-05, 2023-02-01, 2022-09-06

References

1. Hyftor Prescribing Information. Nobelpharma America, LLC. Bethesda, MD. January 2024.

---

End Notes

1. If symptoms do not improve within 12 weeks of treatment, patient should be re-evaluated to determine the need to continue treatment. An additional month is added to the initial authorization duration to allow for patient follow-up with the provider. [1]

---

Revision History

• 2025-01-20: 2025 annual review. No clinical changes.
• 2023-12-29: Annual review. No changes to clinical criteria.
• 2023-11-02: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-10-05: 2023 Annual Review - No changes to criteria
• 2023-02-01: Update prescriber requirement options to include neurologist and geneticist.
• 2022-09-06: New program for Hyftor.

---