oxymetazoline (Rhofade®)

SELF ADMINISTRATION - TOPICAL

Indication for Prior Authorization:

Topical treatment of persistent facial erythema associated with rosacea in adults.

Coverage Criteria:
  • Documented diagnosis of persistent facial erythema due to rosacea; AND
  • Patient is 18 years of age or older; AND
  • Patient has tried and failed Mirvaso® (brimonidine) topical gel; AND
  • For patients with papulopustular rosacea lesions: tried and failed topical metronidazole (MetroLotion®, MetroCream®, or MetroGel®).
     
Dosing:

Apply a pea-sized amount once daily in a thin layer to cover the entire face (forehead, nose, each cheek, and chin) avoiding the eyes and lips. Rhofade® is provided up to 1 tube (30 grams) per month.

Coverage Duration:

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 Committee.

Additional Information:
  • Patients with cardiovascular disease, orthostatic hypotension, and/or uncontrolled hypertension/hypotension should seek medical care if these conditions worsen while using Rhofade®.
  • Use Rhofade® with caution in patients with cerebral or coronary insufficiency, Raynaud’s phenomenon, thromboangiitis obliterans, scleroderma, or Sjögren’s syndrome.  Seek medical care if vascular insufficiency worsens (improper functioning of the vein valves in the leg, causing swelling and skin changes).
  • If signs or symptoms of acute narrow-angle glaucoma develop while using Rhofade®, seek immediate medical care.
Review History:
  • 12/30/2020 – Annual review; format updated
  • 05/01/2017 – New policy approved by P&T
References:
  • Del Rosso JQ, Tanghetti E, Webster G, Gold LS, Thiboutot D, Gallo RL. Update on the management of rosacea from the American Acne & Rosacea Society (AARS). The Journal of clinical and aesthetic dermatology. 2019 Jun;12(6):17.
  • Oge LK, Muncie Jr HL, Phillips-Savoy AR. Rosacea: diagnosis and treatment. American family physician. 2015 Aug 1;92(3):187-96.
  • Rhofade [package insert]. Charleston, SC: EPI Health, LLC; November 2019.

 

Last review date: December 30, 2020

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