EPSOLAY (benzoyl peroxide cream)

EPSOLAY (benzoyl peroxide cream)

Self-Administration – topical

Diagnosis considered for coverage:

•     Indicated for the treatment of inflammatory lesions of rosacea in adults.

Coverage Criteria:

For diagnosis of rosacea:

• Requested quantity does not exceed 30 grams per month, AND
• Patient is 18 years of age or older, AND
• Patient has inflammatory lesions of rosacea as confirmed by chart note documentation, AND
• Patient has tried and failed 2 of the preferred agents within the past 180 days: topical metronidazole, azelaic acid 15%, ivermectin 1% cream
   

Reauthorization Criteria:

For diagnosis of rosacea:

• Requested quantity does not exceed 30 grams per month, AND
• Patient had a positive response to therapy as confirmed by chart note documentation

Coverage Duration:

 
•    Initial: 1 year
•    Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

•    Discard unused Epsolay 30 days after first use.

Policy Updates:

•    11/15/2022 – New policy approved by P&T.

References:

1.    Epsolay Prescribing Information. Galderma Laboratories, LP. Fort Worth, TX. April 2022.